ICD Code M48.48XS

ICD code M4848XS is used to describe a condition where there is a fatigue fracture of the vertebra located in the sacral and sacrococcygeal region, and it is specifically referring to the sequela of this fracture. In medical terms, a "fatigue fracture" is a type of stress fracture that occurs due to repetitive stress or overuse, rather than a single traumatic event. The "sacral and sacrococcygeal region" refers to the lower part of the spine, near the tailbone. The term "sequela" indicates that this code is used for cases where the patient is experiencing a condition or complication that is a direct result of a previous fracture in this area. This could include chronic pain, deformity, or other long-term effects stemming from the original fracture.

When to use the ICD code M4848XS:

1. History of Fracture: The patient has a documented history of a fracture in the vertebra, sacral, or sacrococcygeal region.

2. Current Symptoms: The patient presents with ongoing symptoms related to the previous fracture, such as:

- Persistent pain in the lower back or sacral area

- Limited mobility or difficulty in performing daily activities

- Neurological symptoms, such as numbness or weakness in the lower extremities

3. Radiological Evidence: Imaging studies (e.g., X-rays, MRI) confirm the presence of a fatigue fracture in the specified region, indicating a sequela from the prior injury.

4. Time Frame: The symptoms and findings are occurring after the initial fracture has healed, indicating a sequela rather than an acute injury.

5. Exclusion of Other Conditions: Other potential causes of the symptoms have been ruled out, confirming that the issues are directly related to the prior fracture.

6. Clinical Documentation: Comprehensive clinical documentation supports the diagnosis, including notes on the patient's medical history, treatment received, and any rehabilitation efforts undertaken post-fracture.

For the ICD code M48.48XS, which pertains to a sequela of a fatigue fracture of the vertebra in the sacral and sacrococcygeal region, the relevant CPT codes that may be applicable for treatment include:

1. 22510 - Percutaneous vertebroplasty (bone cement injection) for the sacrum.

2. 22511 - Percutaneous vertebroplasty (bone cement injection) for the sacrum, each additional vertebral body.

3. 22512 - Percutaneous vertebroplasty (bone cement injection) for the sacrum, each additional vertebral body (list separately in addition to code for primary procedure).

4. 27279 - Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance.

5. 27280 - Arthrodesis, open, sacroiliac joint, including obtaining bone graft, including instrumentation, when performed.

These CPT codes are examples of procedures that might be considered in the management of conditions related to the ICD code M48.48XS. It's important for healthcare providers to select the appropriate CPT code based on the specific treatment plan and procedures performed.

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