ICD-10-CM · Spine

M46.48

Inflammation of an intervertebral disc or disc space localized to the sacral or sacrococcygeal region of the spine, where the causative organism or etiology has not been specified in the clinical documentation.

Verified May 8, 2026 · 5 sources ↓

Status: Billable
Chapter: 13
Related CPT: 10
Region: Spine

Drawn from CDCICD10DataAAPCCMS

Documentation tips

What should appear in the chart to support M46.48.

Source · Editorial brief grounded in 5 cited references ↓

Explicitly name the affected region as 'sacral' or 'sacrococcygeal' in the assessment — do not rely on imaging reports alone to establish anatomic specificity.
Record MRI findings supporting discitis: disc space signal change, endplate irregularity, enhancement pattern, and any associated paraspinal or epidural involvement.
Document whether a causative organism has been identified; if cultures or biopsy are pending, note 'etiology undetermined' to justify the 'unspecified' designation.
If discitis followed a spinal procedure (injection, discography, epidural), document the precipitating procedure with date and laterality to support post-procedural complication coding if applicable.
Note the presence or absence of neurologic deficits, fever, or elevated inflammatory markers (ESR, CRP, WBC) to support medical necessity and MCC/CC DRG assignment.

Related CPT procedures

Procedure codes commonly billed with M46.48. Linking the right diagnosis to the right procedure is what establishes medical necessity.

Source · CMS LCDs · AAOS specialty guidance · claims-pattern analysis

72148 $191.72

Non-contrast MRI of the lumbar spine used to evaluate disc pathology, spinal stenosis, nerve root compression, and other structural abnormalities without administration of contrast material.

72158 $318.31

MRI of the lumbar spinal canal and its contents performed first without contrast, then repeated after contrast administration for enhanced visualization.

72195 $227.46

MRI of the pelvis performed without contrast material, producing soft-tissue images of pelvic structures without intravenous dye administration.

27096 $175.69

Injection into the sacroiliac joint with fluoroscopic or CT image guidance, including arthrography when performed.

20610 $68.81

Aspiration and/or injection of a major joint or bursa (shoulder, hip, knee, or subacromial bursa) performed without ultrasound guidance.

72100 $40.42

Radiologic examination of the lumbosacral spine capturing two or three views, used to evaluate the lumbar vertebrae and sacrum for injury, degeneration, or structural abnormality.

72120 $42.09

Radiologic examination of the lumbosacral spine using bending views only, minimum of four views, to assess spinal flexibility and alignment.

22899 View procedure details

62322 View procedure details

62323 View procedure details

Common coding pitfalls

The recurring mistakes coders make with M46.48 and adjacent codes.

Source · Editorial brief grounded in CDC ICD-10-CM tabular guidance, AAOS coding references, and cited references ↓

Coding M46.47 (lumbosacral region) when documentation or imaging localizes the disc inflammation to the sacral or sacrococcygeal level specifically — these are distinct codes.
Using M46.48 when a specific organism is documented; identified infectious discitis belongs under a pyogenic or specific infectious spondylopathy code, not M46.4x.
Defaulting to a nonspecific low back pain code (e.g., M54.50) when MRI findings and clinical documentation confirm discitis — M46.48 is the correct, more specific code.
Failing to add a secondary code for an underlying condition (e.g., immunocompromised state, recent spinal procedure) that clinically explains the discitis presentation.
Assigning M46.48 for lumbosacral discitis when the provider's note says 'lower lumbar/sacral' without clearly specifying the sacral disc — query the provider before coding past the lumbosacral code M46.47.

Clinical context

Source · Editorial summary grounded in 5 cited references ↓

M46.48 is the billable code for discitis confined to the sacral and sacrococcygeal region when the etiology — infectious, chemical, or post-procedural — is not documented or has not yet been established. Use this code when imaging (typically MRI) confirms disc inflammation at the sacral or sacrococcygeal level but culture results are pending, absent, or inconclusive, and the provider has not documented a specific organism.

The sacral and sacrococcygeal region represents the lowest mobile segment of the spinal column. Discitis here is anatomically distinct from lumbosacral discitis (M46.47) and warrants a separate code when the clinical documentation specifically identifies the sacral or sacrococcygeal disc as the affected site. If the causative organism is identified — for example, Staphylococcus aureus — the case belongs under pyogenic vertebral osteomyelitis or a more specific infectious code, not M46.48.

This code groups into MS-DRG 551 (Medical back problems with MCC) or 552 (Medical back problems without MCC) under MS-DRG v43.0. Post-procedural discitis — following discography, epidural injection, myelography, or chemonucleolysis — may be coded here when the sacral or sacrococcygeal disc is involved and no organism is identified, though a code for the procedure-related complication may also be required. Always sequence M46.48 as the principal diagnosis only when it is the condition chiefly responsible for the encounter.

Sibling codes

Other billable codes under M46.4 (laterality / anatomic variants).

M46.42

Discitis, unspecified, cervical region

M46.47

Discitis, unspecified, lumbosacral region

M46.40

Discitis, unspecified, site unspecified

M46.41

Discitis, unspecified, occipito-atlanto-axial region

M46.49

Discitis, unspecified, multiple sites in spine

M46.44

Discitis, unspecified, thoracic region

M46.43

Discitis, unspecified, cervicothoracic region

M46.46

Discitis, unspecified, lumbar region

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 5 cited references ↓

01When should I use M46.48 instead of M46.47?

Use M46.48 when the provider's documentation or imaging specifically identifies the sacral or sacrococcygeal disc as the site of inflammation. M46.47 covers the lumbosacral region. If documentation is ambiguous between the two, query the treating provider before assigning either code.

02Can M46.48 be used for post-procedural discitis after a sacral epidural injection?

Yes, if the sacral or sacrococcygeal disc is the confirmed site of inflammation and no causative organism has been identified. You may also need a code for the post-procedural complication depending on payer requirements and the circumstances of care.

03What if the causative organism is later identified — do I change the code?

Yes. Once a specific organism is documented, the encounter should be coded with the appropriate infectious spondylopathy or pyogenic code rather than M46.48, which is reserved for cases where etiology is unspecified.

04Is M46.48 appropriate when the diagnosis is still suspected and imaging is pending?

For outpatient encounters, code the sign or symptom (e.g., sacral pain) until discitis is confirmed. M46.48 is appropriate once the provider documents a confirmed or established diagnosis of discitis at this level.

05What DRG does M46.48 map to?

M46.48 groups to MS-DRG 551 (Medical back problems with MCC) or MS-DRG 552 (Medical back problems without MCC) under MS-DRG v43.0. Accurate documentation of MCCs — such as sepsis or respiratory failure — drives DRG assignment and reimbursement.

06Is a 7th character required for M46.48?

No. M46.48 is a 6-character M-code and does not require a 7th-character extension. Seventh-character extensions (A/D/S) apply to injury S-codes, not to musculoskeletal disease M-codes.

07What imaging finding best supports M46.48 in the documentation?

MRI with and without contrast is the standard. Document T2 hyperintensity of the disc space, endplate edema or erosion, and any contrast enhancement pattern. Note absence of an identified organism to justify the 'unspecified' designation.

Sources & references

Editorial content was developed using the following public sources. Last verified May 8, 2026.

Mira AI Scribe

The Mira AI Scribe captures the anatomic level (sacral vs. sacrococcygeal), MRI signal characteristics, culture or biopsy status, procedural history, and inflammatory lab values from the encounter note. That data locks in M46.48 over a nonspecific back pain code and prevents a payer downcode or audit flag for insufficient clinical justification.

See how Mira captures M46.48 documentation