M48.02 - Spinal stenosis, cervical region (ICD-10)
ICD-10 code M48.02 - Spinal stenosis, cervical region. Classified under Spondylopathies, this condition involves clinical findings relevant to diagnosis and documentation accuracy.
Overview
Spinal stenosis cervical region under ICD-10 code M48.02 represents a musculoskeletal condition that may impact functional mobility pain perception and overall quality of life.
- Document acuity (acute, subacute, chronic).
- Include anatomic region/level and laterality.
- Correlate symptoms with exam and imaging when used.
- Avoid unspecified codes when details exist in the note.
- Verify payer policy/LCD before procedures.
- Ensure medical necessity is explicit.
Comman symptoms
- Neurogenic claudication with walking/standing
- Relief when flexed (shopping-cart sign)
- Back/leg pain +/- numbness
Red Flag
- Severe or progressive neurologic deficit
- Fever unexplained weight loss night sweats
- History of cancer immunosuppression or IV drug use
- Trauma with suspected fracture
- Bowel/bladder dysfunction or saddle anesthesia
At a Glance
- ICD-10 code: M48.02
- Condition: Spinal stenosis, cervical region
- Category: Spinal Stenosis
- Related ICD-10 codes: M48.06, M48.02, M48.04
- Common CPT links: 99202-99215, 72131-72149 (imaging), 62321/62323 (ESI)
- Use the most specific laterality/region code your note supports.
Overview
Spinal stenosis cervical region under ICD-10 code M48.02 represents a musculoskeletal condition that may impact functional mobility pain perception and overall quality of life.
- Document acuity (acute, subacute, chronic).
- Include anatomic region/level and laterality.
- Correlate symptoms with exam and imaging when used.
- Avoid unspecified codes when details exist in the note.
- Verify payer policy/LCD before procedures.
- Ensure medical necessity is explicit.
Causes & Risk Factors
Spinal stenosis, cervical region (M48.02) can arise from a combination of biomechanical stress, degenerative processes, systemic inflammation, or trauma. Common risk factors include aging, occupational strain, obesity, and genetic predisposition. Lifestyle factors such as poor posture, repetitive movement, or low physical conditioning also contribute to chronic musculoskeletal pain.
Diagnostic Workup
Accurate coding of Spinal stenosis, cervical region requires clear diagnostic workup. Clinicians often rely on physical examination findings such as range of motion limits, palpation tenderness, or neurovascular testing. Imaging-X-ray, MRI, or ultrasound-may confirm degenerative, inflammatory, or structural changes. Laboratory tests are typically ordered if autoimmune or metabolic causes are suspected.
Treatment & Rehabilitation
While this resource focuses on ICD-10 coding, understanding general management helps coders interpret documentation. Treatment for Spinal stenosis, cervical region may include physical therapy, posture correction, ergonomic modifications, or supervised exercise programs. Pharmacologic therapy and procedural interventions should be captured through appropriate CPT and HCPCS codes when documented. Rehabilitation aims to restore strength, range of motion, and prevent recurrence.
Prevention
Preventing recurrent musculoskeletal issues requires a holistic approach-educating patients on stretching routines, core strengthening, and activity modification. For clinicians, structured documentation templates and s can ensure accurate, defensible coding for audit readiness.
Coding Examples
- Example 1: Patient with spinal stenosis cervical region and documented left-sided involvement - code M48.02-L.
- Example 2: Chronic pain after prior injury with imaging-confirmed degeneration - use M48.02 with chronicity modifier where applicable.
- Example 3: Bilateral presentation with limited range of motion - choose most specific laterality code variants.
Audit & Compliance
Ensure ICD-10 coding aligns with payer policies and medical necessity. Redundant use of unspecified codes is a common audit trigger. For complex cases, link diagnosis codes to procedure CPTs in the superbill and verify that documentation supports frequency and modality of care.
Clinical Example
Chief Complaint: Patient presents with spinal stenosis cervical region over the past several weeks reporting intermittent pain and reduced function.
Subjective: The patient describes symptoms as dull aching and aggravated by movement or prolonged posture. Pain score rated 6/10 relieved partially by rest or heat.
Objective: Physical examination reveals localized tenderness reduced range of motion and no neurological deficit. Imaging reviewed indicates findings consistent with spinal stenosis cervical region (M48.02).
Assessment: Spinal stenosis
cervical region (M48.02) - consistent with spinal stenosis.
Plan: Continue conservative management monitor progression and re-evaluate in 4-6 weeks. Documentation supports ICD-10 code usage as primary diagnosis.
Differential Diagnoses
When coding spinal stenosis, cervical region, consider alternative or coexisting conditions that may share similar symptoms. Accurate differentiation ensures correct ICD-10 assignment and proper claim justification.
- Strain
- Sprain
- Tendinitis
- Osteoarthritis
- Soft-tissue injury
Documentation Best Practices
- Document acuity (acute subacute chronic) and laterality when available.
- Capture specific region/level (e.g. cervical vs lumbar; right vs left; primary vs secondary OA).
- Link symptoms to exam and imaging findings when relevant; avoid unsupported specificity.
- Use the most specific code supported by the note; avoid unspecified when details exist.
- Check payer policy and NCD/LCD rules; include conservative care attempts if required.
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