M46.01
BillableSpinal enthesopathy, occipito-atlanto-axial region
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 at the base of the skull and upper neck area.
Coding Tips
- •This is a rare site for enthesopathy; verify documentation specifically mentions occipito-atlanto-axial region involvement
- •May present with neck pain or headaches; ensure proper clinical correlation
Clinical Significance
Spinal enthesopathy affecting the occipito-atlanto-axial region involves inflammation at critical upper cervical ligament attachments, potentially affecting head and neck stability. This location requires careful neurological monitoring and may be associated with increased risk of cervical spine complications.
Documentation Requirements
- ✓Clinical evidence of upper cervical entheseal inflammation
- ✓Imaging showing occipito-atlanto-axial entheseal changes
- ✓Neurological examination documenting cervical spine stability
- ✓Assessment for atlantoaxial subluxation risk
- ✓Documentation of neck pain and movement restrictions
- ✓Evaluation for associated spondyloarthritis conditions
- ✓Response to targeted anti-inflammatory therapy
- ✓Monitoring for myelopathy signs and symptoms
Commonly Confused Codes
M46.02 — Cervical enthesopathy when specifically upper cervicalM45.A1 — Non-radiographic axial spondyloarthritis when enthesopathy is primaryM50.30 — Cervical disc degeneration without entheseal involvementM53.1 — Cervical instability without inflammatory componentM99.01 — Segmental dysfunction without entheseal inflammation
Code Hierarchy
└M46Other inflammatory spondylopathies└M46.0Spinal enthesopathy└M46.01Spinal enthesopathy, occipito-atlanto-axial region
└M46.01Spinal enthesopathy, occipito-atlanto-axial region