M46.03
BillableSpinal enthesopathy, cervicothoracic 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 where the neck meets the mid-back.
Coding Tips
- •Verify the condition involves the cervicothoracic junction specifically, not isolated cervical or thoracic regions
- •May present with pain at the base of the neck or upper back; ensure proper anatomical documentation
Clinical Significance
Spinal enthesopathy of the cervicothoracic region affects the transition zone between neck and mid-back where mechanical stress is highest. This location often correlates with occupational factors and may require comprehensive ergonomic assessment and workplace modifications.
Documentation Requirements
- ✓Clinical evidence of cervicothoracic entheseal inflammation
- ✓Imaging findings at the cervicothoracic junction
- ✓Documentation of transition zone pain patterns
- ✓Assessment of both cervical and thoracic mobility
- ✓Evaluation for postural and occupational factors
- ✓Response to multimodal anti-inflammatory treatment
- ✓Ergonomic assessment when relevant
- ✓Associated spondyloarthritis screening
Commonly Confused Codes
M46.02 — Cervical region when thoracic component is also involvedM46.04 — Thoracic region when cervical component is also involvedM45.A3 — Non-radiographic axial spondyloarthritis when primary diagnosisM54.2 — Cervicalgia without thoracic involvementM54.6 — Thoracic pain without cervical involvement
Code Hierarchy
└M46Other inflammatory spondylopathies└M46.0Spinal enthesopathy└M46.03Spinal enthesopathy, cervicothoracic region
└M46.03Spinal enthesopathy, cervicothoracic region