Non-radiographic axial spondyloarthritis of lumbosacr region

This code signifies a chronic inflammatory condition primarily affecting the spine and sacroiliac joints, specifically in the lumbosacral region, without clear radiographic evidence of sacroiliitis. Patients typically present with inflammatory back pain, stiffness, and potentially peripheral joint involvement, but imaging studies like X-rays do not show the characteristic structural damage seen in ankylosing spondylitis.

Use this code for patients diagnosed with non-radiographic axial spondyloarthritis (nr-axSpA) where the primary site of involvement is the lumbosacral spine. Documentation should clearly state the diagnosis of nr-axSpA, specify the lumbosacral region, and indicate the absence of definitive radiographic sacroiliitis, often supported by MRI findings showing active inflammation.

• Ensure documentation explicitly states "non-radiographic" to differentiate from ankylosing spondylitis.
• Do not use this code if radiographic evidence of sacroiliitis is present; instead, consider codes for ankylosing spondylitis (M45.0-M45.9).
• Consider sequencing this code as the primary diagnosis when it is the reason for the encounter, followed by any associated manifestations or complications.