Radiology Coding Alert

Question: My radiologist 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 influence 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.

The radiologist will typically diagnose via magnetic resonance imaging (MRI) scans. However, what’s more likely is the diagnosis will appear on the indication of the MRI report based on a referring physicians’ independent exam and/or lab testing.

Treatment options for ankylosing spondylitis include nonsteroidal anti-inflammatory drugs, or NSAIDs, and disease-modifying antirheumatic drugs, or DMARDs, to reduce inflammation and relieve pain.