M46.20
BillableOsteomyelitis of vertebra, site unspecified
HCC Category Mapping
V28HCC 92 — Bone/Joint/Muscle Infections/Necrosis
0.209V24HCC 39 — Bone/Joint/Muscle Infections/Necrosis
0.482ESRDHCC 39 — Bone/Joint/Muscle Infections/Necrosis
0.000What This Code Means
A bone infection (osteomyelitis) affecting one or more vertebrae in the spine, but the specific location is not documented.
Coding Tips
- •This is an unspecified code; always attempt to obtain documentation of the specific vertebral region to use a more specific M46.2x code
- •Osteomyelitis is typically infectious; verify if causative organism is documented for potential additional coding
Clinical Significance
Vertebral osteomyelitis is a serious bone infection that can lead to spinal instability, neurological complications, and sepsis. This condition requires aggressive antibiotic therapy and close monitoring for complications including spinal cord compression.
Documentation Requirements
- ✓Documentation of bone infection (osteomyelitis) in vertebrae
- ✓Clinical signs of infection including fever, pain, or elevated inflammatory markers
- ✓Imaging findings consistent with vertebral osteomyelitis
- ✓Laboratory evidence supporting infection diagnosis
- ✓Documentation that specific vertebral site is unspecified
- ✓Exclusion of other causes of back pain
- ✓Treatment with appropriate antimicrobial therapy
- ✓Assessment for complications such as abscess or neurological symptoms
Commonly Confused Codes
M46.21-M46.28 — Site-specific vertebral osteomyelitis codes when location is knownM86.9 — Osteomyelitis unspecified site doesn't specify vertebral involvementM46.30-M46.39 — Infection of intervertebral disc is different structureG06.1 — Intraspinal abscess may coexist but is different conditionA41.9 — Sepsis may be consequence but is systemic infection
Code Hierarchy
└M46Other inflammatory spondylopathies└M46.2Osteomyelitis of vertebra└M46.20Osteomyelitis of vertebra, site unspecified
└M46.20Osteomyelitis of vertebra, site unspecified