ICD Code M48.58XA

ICD code M4858XA is used to classify a medical condition involving a collapsed vertebra in the sacral and sacrococcygeal region, which is not specified elsewhere in the classification system. This code specifically indicates that it is the initial encounter for the fracture, meaning it is the first time the patient is being treated for this particular injury. The sacral and sacrococcygeal region refers to the lower part of the spine, near the tailbone. This code is crucial for healthcare providers to accurately document and bill for the treatment of this specific spinal injury, ensuring proper reimbursement and continuity of care.

When to use the ICD code M4858XA:

1. Diagnosis of a Collapsed Vertebra: The patient must have a confirmed diagnosis of a collapsed vertebra in the sacral or sacrococcygeal region.

2. Fracture Confirmation: There should be evidence of a fracture, which may be identified through imaging studies such as X-rays, CT scans, or MRIs.

3. Initial Encounter: The coding is applicable only during the initial encounter for treatment of the fracture. This means the patient is receiving care for the first time related to this specific injury.

4. Absence of Specific Classification: The diagnosis must not fall under any other specific classification of vertebral fractures, indicating that it is not categorized elsewhere in the ICD coding system.

5. Clinical Symptoms: The patient may present with symptoms such as:

- Severe localized pain in the lower back or sacral area.

- Limited mobility or difficulty in movement due to pain.

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

6. History of Trauma or Osteoporosis: There may be a relevant history of trauma or conditions such as osteoporosis that could contribute to the vertebral collapse.

7. Physical Examination Findings: The physical examination should reveal tenderness over the affected area, and possibly signs of neurological impairment if the fracture has affected surrounding structures.

By adhering to these diagnostic criteria and symptoms, healthcare providers can accurately determine when to apply the ICD code M4858XA in their documentation and billing processes.

For the ICD code M48.58XA, which pertains to a collapsed vertebra in the sacral and sacrococcygeal region during the initial encounter for fracture, the relevant CPT codes that may be applicable include:

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

2. 22511 - Percutaneous vertebroplasty, including cavity creation (fracture reduction and bone biopsy included when performed) for the sacrum.

3. 22512 - Additional vertebral body, percutaneous vertebroplasty, including cavity creation (fracture reduction and bone biopsy included when performed) for the sacrum.

4. 27216 - Closed treatment of sacral fracture(s); without manipulation.

5. 27217 - Closed treatment of sacral fracture(s); with manipulation, with or without anesthesia.

6. 27218 - Open treatment of sacral fracture(s), includes internal fixation, when performed.

These CPT codes are typically used for procedures related to the treatment of a collapsed vertebra in the sacral region. It is important for healthcare providers to verify the specific procedures performed and ensure accurate coding for proper billing and reimbursement.

Discover how MD Clarity's RevFind software can enhance your revenue cycle management by accurately reading your contracts and identifying underpayments for CPT codes associated with ICD code M4858XA. Schedule a demo today to see how RevFind can help ensure you're receiving the full reimbursement you deserve.