ICD 10 CM M48.38 | Description & Clinical Information

ICD 10 M48.38 describes a condition known as traumatic spondylopathy, which is characterized by disease of the vertebrae resulting from trauma, such as that caused by automobile accidents, sports activities, or hyperextension and hyperflexion injuries, and can lead to the development of bulging intervertebral discs, bone spurs on the spine, and thickening of the facet joints, and this code is specifically applicable to traumatic spondylopathy that occurs in the sacral and sacrococcygeal regions, which are located at the base of the spine and the tailbone.

Official Description Of M48.38

The ICD 10 CM book defines ICD 10 code M48.38 as:

Traumatic spondylopathy, sacral and sacrococcygeal region

Clinical Information

The diagnosis describes by the ICD 10 CM M48.38 code revolves around traumatic spondylopathy of the sacral and sacrococcygeal region. This condition primarily manifests itself as pain in the back and buttocks region often accompanied by burning, tingling sensations, numbness, and radiating pain to the lower extremities. Additionally, patients with this condition may experience restricted back and hip motions, making everyday activities challenging to perform.

Medical providers typically diagnose the condition based on a thorough examination of the patient’s medical history and physical symptoms. A healthcare professional may perform a neurological examination, which assesses the patient’s sensation, muscle strength, and reflexes. Furthermore, providers may conduct a range of imaging techniques, such as X-rays, computed tomography (CT) scans, CT myelography, discography and magnetic resonance imaging (MRI), depending on the patient’s symptoms.

In cases where the condition’s symptoms are minor, no treatment may be necessary, and symptoms may resolve themselves in a few weeks. However, patients that experience more severe symptoms may require treatment. Several treatment options exist, including medication such as analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, and muscle relaxants. Short-term narcotics for pain relief may also be an option if other medications are not effective.

Other forms of treatment for traumatic spondylopathy may include hot baths and sauna therapy, a soft collar or orthosis to limit motion, and physical therapy to improve flexibility and muscle strength. In rare cases, surgery may be necessary if conservative treatment options fail.

Therefore, as a medical coder, understanding the ICD 10 CM M48.38 diagnosis code is crucial in correctly identifying and documenting traumatic spondylopathy in medical records. By having an in-depth knowledge of the symptoms and treatment options, medical coders can help ensure that patients with painful and disabling conditions receive the appropriate medical care they need to manage their symptoms effectively.

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