ICD Code M48.58XG

ICD code M4858XG is used to classify a medical condition involving a collapsed vertebra in the sacral and sacrococcygeal region, which is not specified elsewhere in the ICD coding system. This particular code is designated for a subsequent encounter, indicating that the patient has already received initial treatment for the fracture, and it is now being addressed again due to delayed healing. This code helps healthcare providers accurately document and track the patient's ongoing treatment and recovery process, ensuring that the specific nature of the fracture and its healing complications are clearly communicated for billing and clinical purposes.

When to use the ICD code M4858XG:

1. Diagnosis of a Collapsed Vertebra

- Confirmed diagnosis of a vertebral collapse in the sacral or sacrococcygeal region.

2. Fracture Status

- The vertebral collapse is due to a fracture that has been previously diagnosed.

3. Subsequent Encounter

- The patient is returning for follow-up care after the initial treatment of the fracture.

4. Delayed Healing

- Evidence of delayed healing of the fracture, which may be indicated by imaging studies or clinical evaluation.

5. Exclusion of Other Conditions

- Other potential causes of vertebral collapse have been ruled out, ensuring that the diagnosis is specific to the condition described.

6. Clinical Symptoms

- Presence of symptoms such as pain in the lower back or sacral region, neurological deficits, or mobility issues related to the vertebral collapse.

7. Treatment Plan

- A documented treatment plan that addresses the ongoing management of the fracture and its complications, including any interventions aimed at promoting healing.

For the ICD code M4858XG, which pertains to a collapsed vertebra in the sacral and sacrococcygeal region with delayed healing, 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, additional level.

3. 22512 - Percutaneous vertebroplasty, each additional level.

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

5. 27218 - Closed treatment of sacral fracture; with manipulation.

6. 27220 - Open treatment of sacral fracture, includes internal fixation, when performed.

7. 20982 - Implantation of biomechanical device(s) for spine stabilization, with or without bone graft, including anterior or lateral approach technique.

These CPT codes are examples of procedures that may be considered for the treatment of a collapsed vertebra in the sacral region, depending on the specific clinical scenario and treatment plan determined by the healthcare provider. Always consult with a coding specialist or the latest coding guidelines to ensure accurate and up-to-date coding.

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