M46.00
BillableSpinal enthesopathy, site unspecified
HCC Category Mapping
V24HCC 40 — Rheumatoid Arthritis and Inflammatory Connective Tissue Disease
0.307ESRDHCC 40 — Rheumatoid Arthritis and Inflammatory Connective Tissue Disease
0.000What This Code Means
Inflammation where tendons and ligaments attach to the spine, but the specific location along the spine is not documented.
Coding Tips
- •This is an unspecified code; attempt to obtain more specific anatomical documentation from the provider
- •Use only when the spinal region cannot be determined from available documentation
Clinical Significance
Spinal enthesopathy represents inflammation at sites where ligaments and tendons attach to vertebrae, often associated with spondyloarthritis conditions. This finding requires evaluation for underlying systemic inflammatory arthritis and may predict progression to more severe spinal disease.
Documentation Requirements
- ✓Clinical evidence of entheseal inflammation along the spine
- ✓Imaging findings showing entheseal changes
- ✓Documentation of pain at tendon/ligament attachment sites
- ✓Assessment for associated spondyloarthritis features
- ✓Response to anti-inflammatory medications
- ✓Evaluation for peripheral enthesitis
- ✓Screening for HLA-B27 and related conditions
- ✓Functional impact assessment
Commonly Confused Codes
Site-specific enthesopathy codes when location is documentedM76.9 — Enthesopathy of lower limb when spinal involvement is presentM77.9 — Enthesopathy of upper limb when spinal involvement is presentM45.9 — Ankylosing spondylitis when enthesopathy is the primary findingM54.9 — Dorsalgia when inflammatory entheseal component is established
Code Hierarchy
└M46Other inflammatory spondylopathies└M46.0Spinal enthesopathy└M46.00Spinal enthesopathy, site unspecified
└M46.00Spinal enthesopathy, site unspecified