Neurosurgery Coding Alert

Question: My neurosurgeon documented a diagnosis of ankylosing spondylitis of the cervical region. Can you explain what ankylosing spondylitis is and which ICD-10-CM code I should report? 

Ohio Subscriber

Answer: For ankylosing spondylitis of the cervical region, you should report M45.2 (Ankylosing spondylitis of cervical region).

Ankylosing spondylitis defined: Ankylosing spondylitis is an arthritic disorder of the spine. Although the exact cause of ankylosing spondylitis is not known, experts believe that a patient’s genetics influences this condition. In fact, many patients with ankylosing spondylitis test positive for the gene HLA-B27. Patients affected by ankylosing spondylitis are usually young adults in their late twenties or early thirties, and men are more likely to develop this condition than women.

Any region in the spine can be affected by ankylosing spondylitis, and a patient with this disease usually experiences pain and stiffness of the back, mainly in the low back, buttocks, and sacroiliac joints. Patients may also experience pain in their ligaments and tendons, fever, fatigue, loss of appetite, and eye inflammation. The patient’s vertebrae may fuse together, resulting in spinal stiffness and limited mobility. The patient may also develop a stooped posture and face challenges performing daily routine activities.

You surgeon will diagnose ankylosing spondylitis based upon the patient’s history, a physical exam, imaging techniques like x-rays and magnetic resonance imaging (MRI), as well as a lab test of inflammatory markers and genetic testing for the presence of HLA-B27.

Treatment options for ankylosing spondylitis includes nonsteroidal anti-inflammatory drugs, or NSAIDs, and disease modifying antirheumatic drugs, or DMARDs, to reduce inflammation and relieve pain. Also, your surgeon may recommend physical and occupational therapy, exercise, and joint replacement surgery, if necessary.