Spondylosis w/o myelopathy or radiculopathy, cervical region

This code signifies degenerative changes in the cervical spine, such as osteophytes and disc space narrowing, without evidence of spinal cord compression (myelopathy) or nerve root impingement (radiculopathy). It describes a patient experiencing cervical spondylosis where neurological deficits are absent.

Use this code when documentation confirms cervical spondylosis based on imaging (e.g., X-ray, MRI) and clinical assessment shows no signs or symptoms of myelopathy (e.g., gait disturbance, hyperreflexia) or radiculopathy (e.g., dermatomal pain, weakness, sensory loss). This code is appropriate for patients presenting with neck pain attributed to degenerative changes without neurological compromise.

• Ensure the physician explicitly states the absence of myelopathy and radiculopathy in the cervical region.
• Do not use this code if any neurological symptoms or signs are documented; instead, select a more specific code indicating myelopathy or radiculopathy.
• Consider additional codes for associated symptoms like cervicalgia (M54.2) if documented.