Spondylopathies

Non-radiographic axial spondyloarthritis (nr-axSpA) affecting the spine at an unspecified vertebral region — inflammatory sacroiliitis confirmed on MRI without corresponding plain-film radiographic changes.

Non-radiographic axial spondyloarthritis localized to the occipito-atlanto-axial region — the articulations between the occiput, atlas (C1), and axis (C2) — where active inflammation is confirmed by MRI or clinical criteria but plain radiographs show no definitive structural damage.

M45.A2 identifies non-radiographic axial spondyloarthritis (nr-axSpA) localized to the cervical spine — an inflammatory spondyloarthropathy meeting clinical and MRI criteria for axSpA but lacking the structural sacroiliac changes visible on plain radiographs required for an ankylosing spondylitis diagnosis.

Inflammatory axial spondyloarthritis localized to the cervicothoracic spinal region (C7–T1 junction) in which structural damage — sacroiliitis or syndesmophytes — is absent on plain radiographs but may be detectable on MRI.

Axial spondyloarthritis affecting the thoracic spine in which inflammatory disease activity is confirmed clinically and by MRI or laboratory markers but spinal or sacroiliac joint changes are absent on plain radiographs.

Non-radiographic axial spondyloarthritis localized to the thoracolumbar junction (T12–L1 region), confirmed by clinical criteria and MRI findings rather than plain radiographic sacroiliitis.

Axial spondyloarthritis of the lumbar spine with active inflammation confirmed by MRI or clinical criteria but without the structural sacroiliac joint damage visible on plain radiographs that defines ankylosing spondylitis.

Non-radiographic axial spondyloarthritis confined to the lumbosacral region — inflammatory spondyloarthritis with active sacroiliitis on MRI or positive HLA-B27 but no definitive structural damage visible on plain radiograph.

Non-radiographic axial spondyloarthritis localized to the sacral and sacrococcygeal region, where inflammatory sacroiliitis is confirmed by MRI or clinical/lab criteria but structural damage is absent on plain radiographs.

Non-radiographic axial spondyloarthritis (nr-axSpA) involving two or more distinct spinal regions simultaneously, where active spinal inflammation is confirmed but without the structural sacroiliac joint damage visible on plain radiographs.

M46.00 classifies spinal enthesopathy — pathological changes at ligamentous or muscular attachment points along the spine — when the specific spinal region is not documented or cannot be determined.

Pathological disorder of ligamentous or muscular attachment sites at the occipito-atlanto-axial region of the spine — the junction of the skull base (occiput), atlas (C1), and axis (C2).

Disorder of ligamentous or muscular attachments (entheses) at the cervical spine, classified under other inflammatory spondylopathies.

Pathological changes affecting the ligamentous or muscular attachment sites along the cervicothoracic junction of the spine, spanning the transitional zone where the cervical spine meets the thoracic spine.

M46.04 identifies pathological changes at the tendon and ligament insertion sites along the thoracic spine (T1–T12), classified under other inflammatory spondylopathies.

Pathological changes at the tendon and ligament insertion points along the thoracolumbar junction (approximately T12–L1), classified under inflammatory spondylopathies.

M46.06 identifies a disorder of the ligamentous or muscular attachments along the lumbar spine (L1–L5), classifying it as a spinal enthesopathy with inflammatory spondylopathy characteristics.

M46.07 identifies pathological changes at the ligamentous or muscular attachment points along the lumbosacral spine — the transitional zone where the lumbar vertebrae meet the sacrum.

Pathological changes at the ligamentous and muscular attachment sites of the spine within the sacral and sacrococcygeal region, including inflammatory or degenerative disruption at the sacrum or coccyx insertions.

Pathological changes at the ligamentous and muscular attachment points along the spine, affecting two or more distinct spinal regions simultaneously.

Vertebral osteomyelitis with no spinal region documented — use only when the treating clinician has not specified which section of the spine is affected.

Bacterial or fungal infection of the vertebral bone at the occipito-atlanto-axial region — the anatomical junction encompassing the occiput (C0), atlas (C1), and axis (C2) — producing active osteomyelitis of the uppermost cervical spine.

Bacterial or other microbial infection of the vertebral bone body within the cervical spine (C1–C7), classified under other inflammatory spondylopathies.

Bacterial or other microbial infection of vertebral bone at the cervicothoracic junction (C7–T1 transition zone), classified under other inflammatory spondylopathies.

Bacterial or hematogenous infection of one or more vertebral bodies localized to the thoracic spine (T1–T12), classified under other inflammatory spondylopathies.

Infectious inflammation of vertebral bone tissue specifically involving the thoracolumbar junction (T12-L1 region), classified under other inflammatory spondylopathies.

Bacterial or hematogenous infection of the vertebral bone body confined to the lumbar spinal region (L1–L5), classified under other inflammatory spondylopathies.

M46.27 captures bone infection (osteomyelitis) localized to the vertebrae of the lumbosacral region — specifically the junction of the lumbar spine and sacrum (L5-S1 level and associated structures).

Bacterial or other microbial infection involving the osseous structures of the sacral vertebrae and/or the sacrococcygeal junction, classified under other inflammatory spondylopathies.

Pyogenic (bacterial) infection of an intervertebral disc where the spinal region has not been documented or specified by the treating provider.

Pyogenic (bacterial) infection of the intervertebral disc located in the occipito-atlanto-axial region — spanning the articulations between the occiput, atlas (C1), and axis (C2).

Pyogenic (bacterial) infection localized to an intervertebral disc in the cervical spine region, classified under other inflammatory spondylopathies.

Pyogenic bacterial infection of the intervertebral disc localized to the cervicothoracic spinal region, spanning the C7-T1 junction.

Pyogenic (bacterial) infection of an intervertebral disc localized to the thoracic spine, classified under other inflammatory spondylopathies.

Pyogenic (bacterial) infection of the intervertebral disc at the thoracolumbar junction, typically spanning the T12–L1 level, resulting in discitis caused by an identified or presumed bacterial organism.

Pyogenic (bacterial) infection of one or more intervertebral discs in the lumbar spine region, classified under other inflammatory spondylopathies.

Pyogenic (bacterial) infection of the intervertebral disc at the lumbosacral junction (L5–S1 level), classified under other inflammatory spondylopathies.

Pyogenic (bacterial) infection of the intervertebral disc located at the sacral or sacrococcygeal spinal level, classified under other inflammatory spondylopathies.

Pyogenic (bacterial) infection involving intervertebral discs at more than one spinal region simultaneously, classified under other inflammatory spondylopathies.

M46.40 identifies discitis — inflammation of an intervertebral disc — when neither the specific spinal region nor the etiology is documented in the medical record.

Discitis of unspecified type involving the occipito-atlanto-axial region — the articulations between the occiput, atlas (C1), and axis (C2) — where the etiology (bacterial, viral, or aseptic) has not been documented.

Inflammation of one or more intervertebral discs in the cervical spine region, where the specific etiology has not been documented or confirmed.

Inflammation of an intervertebral disc at the cervicothoracic junction (C7-T1 region) where the etiology has not been specified as infectious, pyogenic, or otherwise classified.

Inflammation of an intervertebral disc in the thoracic spine where the underlying cause has not been specified or confirmed in the clinical documentation.

Inflammation of one or more intervertebral discs located at the thoracolumbar junction (T12–L1 transition zone), with the etiology unspecified — meaning the record does not distinguish infectious, inflammatory, or other origin.

M46.46 designates inflammation of an intervertebral disc in the lumbar region (L1–L5) where the causative organism has not been identified or specified in the clinical record.

Inflammation of an intervertebral disc at the lumbosacral junction (L5-S1 level) where the causative organism or inflammatory mechanism has not been specified in the medical record.

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.

Discitis at multiple spinal levels where the causative organism has not been identified or specified in the clinical documentation.

Infectious involvement of the spine without a documented or determinable vertebral site — used when the spinal region affected by infection has not been specified in clinical documentation.

Infectious inflammation of the spinal structures at the occipito-atlanto-axial region (C0–C1–C2 junction) caused by a pathogen not classified elsewhere in the M46 category.

Infectious inflammation of the vertebrae and surrounding spinal structures localized to the cervical (C1–C7) region, caused by a pathogen other than tuberculosis or brucellosis.

M46.53 classifies infectious spondylopathy affecting the cervicothoracic region (C7–T1 junction) that does not fall under a more specific infective spinal diagnosis such as tuberculous spondylitis (M45) or pyogenic vertebral osteomyelitis coded elsewhere.

Infectious spinal disease affecting the thoracic vertebrae (T1–T12) caused by a pathogen other than those classified under osteomyelitis of vertebra (M46.2) or pyogenic intervertebral disc infection (M46.3).

Infective spondylopathy of non-pyogenic or atypical origin affecting the junction of the thoracic and lumbar spine (T12-L1 region), where the infectious process does not fall under more specific categories such as tuberculosis or brucellosis.

M46.56 classifies infectious conditions of the lumbar vertebrae and surrounding spinal structures that are not captured by more specific infective spondylopathy codes (e.g., pyogenic vertebral osteomyelitis or tuberculous spondylitis), localized to the L1–L5 region.

Infectious inflammation of the spinal vertebrae and associated structures localized to the lumbosacral junction (L5-S1 region), caused by organisms other than those classified under tuberculosis or other specific infective spondylopathies.

M46.58 identifies infectious disease involving the vertebral structures of the sacral and sacrococcygeal region — the lower sacrum through the coccyx — caused by pathogens other than those classified under pyogenic or tuberculous spondylitis codes.

Infectious disease process affecting the vertebrae and surrounding spinal structures at two or more non-contiguous or contiguous regions of the spine, caused by organisms other than those classified under pyogenic or tuberculous spondylitis.

M46.80 classifies a documented inflammatory spondylopathy that is specified by type but lacks documentation of which spinal region is affected.