Non-radiographic axial spondyloarthritis of cervical region

This code signifies a chronic inflammatory arthritic condition primarily affecting the cervical spine, where characteristic radiographic changes of sacroiliitis are absent. Patients experience persistent neck pain and stiffness due to inflammation of the axial skeleton, without definitive structural damage visible on conventional X-rays. It represents an early stage or a specific phenotype of spondyloarthritis.

Apply this code when documentation confirms a diagnosis of non-radiographic axial spondyloarthritis specifically impacting the cervical region. This diagnosis is typically made based on clinical symptoms, inflammatory markers, MRI findings showing active inflammation in the cervical spine, and the absence of clear radiographic sacroiliitis. Physician documentation must explicitly state "non-radiographic axial spondyloarthritis of cervical region" or equivalent.

• Ensure the documentation clearly specifies "non-radiographic" and the "cervical region" to differentiate from other forms of spondyloarthritis.
• Do not use this code if radiographic evidence of sacroiliitis is present; instead, consider codes for ankylosing spondylitis (M45.0-).
• Always review the entire medical record for supporting diagnostic criteria, including imaging reports (especially MRI) and rheumatologist notes.