M46.31

Billable

Infection of intervertebral disc (pyogenic), occipito-atlanto-axial region

HCC Category Mapping

V28HCC 92 — Bone/Joint/Muscle Infections/Necrosis

0.209

V24HCC 39 — Bone/Joint/Muscle Infections/Necrosis

0.482

ESRDHCC 39 — Bone/Joint/Muscle Infections/Necrosis

0.000

What This Code Means

A bacterial infection of the intervertebral discs in the upper neck region where the skull connects to the spine.

Coding Tips

•This is a rare site for discitis; verify documentation carefully and ensure imaging confirms disc involvement
•Consider the proximity to critical neurological structures and document any neurological symptoms or complications

Clinical Significance

Pyogenic disc infection in the occipito-atlanto-axial region is particularly serious due to proximity to the brainstem and critical neurovascular structures. This location requires urgent treatment and careful neurological monitoring due to potential for catastrophic complications.

Documentation Requirements

✓Specific anatomical location (occipito-atlanto-axial region)
✓Bacterial etiology confirmation through cultures or clinical evidence
✓Advanced imaging findings (MRI showing disc space enhancement)
✓Neurological examination findings
✓Laboratory markers of infection (ESR, CRP, WBC)
✓Antibiotic sensitivity patterns when available
✓Any associated cervical instability
✓Surgical intervention details if performed

Commonly Confused Codes

M46.30 — Pyogenic disc infection, site unspecified when location not documented M46.51 — Other infective spondylopathies same region when non-bacterial G93.1 — Anoxic brain damage when neurological complications occur M48.02 — Spinal stenosis, cervical region when structural rather than infectious

Code Hierarchy

└M46Other inflammatory spondylopathies └M46.3Infection of intervertebral disc (pyogenic)└M46.31Infection of intervertebral disc (pyogenic), occipito-atlanto-axial region

└M46.31Infection of intervertebral disc (pyogenic), occipito-atlanto-axial region