Infection of intervertebral disc (pyogenic), multiple sites in spine
ICD-10 M46.39 is a billable code used to indicate a diagnosis of infection of intervertebral disc (pyogenic), multiple sites in spine.
M46.39 refers to a pyogenic infection of the intervertebral discs located at multiple sites within the spine. This condition is characterized by the presence of bacteria that invade the disc space, leading to inflammation, pain, and potential neurological deficits. The infection can arise from hematogenous spread, direct extension from adjacent structures, or post-surgical complications. Clinically, patients may present with severe back pain, fever, and neurological symptoms depending on the extent of the infection and any resultant spinal cord compression. Diagnosis typically involves imaging studies such as MRI, which can reveal disc space involvement and associated abscess formation. Laboratory tests may show elevated inflammatory markers and cultures may identify the causative organism. Treatment often requires a combination of antibiotics and, in some cases, surgical intervention to decompress the affected area and remove infected tissue. Early diagnosis and management are crucial to prevent long-term complications such as chronic pain or disability.
Detailed operative notes, imaging results, and pathology reports are essential.
Post-operative infections following spinal surgery, acute discitis in patients with fever and back pain.
Ensure that the surgical history is clearly documented to support the diagnosis of infection.
Comprehensive lab results, culture reports, and treatment plans must be included.
Patients presenting with systemic signs of infection and localized back pain.
Document the organism identified and the treatment response to support the diagnosis.
Used in cases where surgical intervention is required to decompress the spinal cord due to infection.
Operative report detailing the procedure and indication for surgery.
Orthopedic surgeons must document the rationale for surgical intervention clearly.
M46.39 is used for pyogenic infections of multiple intervertebral discs, while M46.2 is for infections at a single site. Accurate documentation of the number of affected sites is crucial for correct coding.
