Other spondylosis with myelopathy, thoracolumbar region

This code signifies a degenerative condition of the spine in the thoracic and/or lumbar regions, characterized by the formation of osteophytes and disc degeneration, which results in compression of the spinal cord. This compression, known as myelopathy, leads to neurological deficits such as weakness, sensory changes, and gait disturbances.

Assign this code when documentation clearly indicates spondylosis affecting the thoracic and/or lumbar spine, accompanied by clinical signs and symptoms of spinal cord compression. Supporting documentation includes neurological examination findings, imaging reports (MRI, CT) demonstrating spinal cord impingement, and physician notes confirming the diagnosis of myelopathy secondary to spondylosis.

• Ensure documentation explicitly states "myelopathy" in conjunction with thoracolumbar spondylosis; otherwise, a code for spondylosis without myelopathy may be more appropriate.
• Do not use this code if the myelopathy is due to a traumatic injury or other non-spondylotic causes.
• Sequence this code as the primary diagnosis when the myelopathy is the reason for the encounter or treatment.