Orthopedic Coding Alert

Question: During the course of a level-two evaluation and management (E/M) service for a new patient, the provider diagnosed, according to the notes, "discitis." The provider did not specify any type of discitis. What is discitis, and is this enough information to choose the correct ICD-10 code?

Delaware Subscriber

Answer: You're going to need to ask the provider for more detail before zeroing in on the correct code for your 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making ...) encounter.

Definition: According to the Medical University of South Carolina website, discitis is an "infection of the discs between the vertebra of the spine. Like appendicitis, discitis is usually a bacterial infection but may be viral. A major issue for the discs is that they do not have a good blood supply and so if bacteria or virus are there, the body's immune cells as well as a physician's antibiotics have great difficulty getting to the infection since they are conveyed there by the blood stream."

Thus, "if infection of the disc occurs, it is very difficult to treat, and this is why discitis is such a big problem to those who contract it," according to the website.

ICD-10 coding: The ICD-10 manual lays out the following codes for discitis when the provider doesn't specify the type:

• M46.40 - Discitis, unspecified, site unspecified
• M46.41 - ... occipito-atlanto-axial region 
• M46.42 - ... cervical region
• M46.43 - ... cervicothoracic region
• M46.44 - ... thoracic region
• M46.45 - ... thoracolumbar region
• M46.46 - ... lumbar region
• M46.47 - ... lumbosacral region
• M46.48 - ... sacral and sacrococcygeal region
• M46.49 - ... multiple sites in spine.

Best bet: Go back and check with the provider to see she has any more information about the specific type of discitis. This could lead you to a more accurate ICD-10 code choice. If you cannot find any other info on the patient's condition, your best bet is likely M46.40.