ICD-10-CM Billable Code

M43.11

Spondylolisthesis, occipito-atlanto-axial region

Clinical Classification Guidelines

Medical Intelligence & Overview

Spondylolisthesis in the occipito-atlanto-axial region involves the displacement of one vertebra relative to another within the upper neck, specifically around the skull base and upper cervical spine. This condition can affect movement and stability in the neck and may lead to neurological symptoms. While less common in this region compared to lower spine issues, understanding the causes, symptoms, diagnosis, and potential treatments can help in managing this condition effectively.

Causes & Symptoms

Clinical Causes: Congenital defects that affect the development of cervical vertebrae Traumatic injuries resulting from accidents or blows to the head or neck Degenerative changes due to aging or wear and tear on the cervical spine Arthritis-related degeneration of the joints in the upper neck Previous neck surgeries or structural abnormalities

Key Symptoms: Neck pain or stiffness, especially at the base of the skull Limited range of motion in the neck Headaches, often starting at the neck and radiating to the scalp Muscle weakness or numbness in the arms or hands Dizziness or vertigo in some cases Signs of nerve compression such as tingling or radiating pain Balance problems or difficulty walking in severe cases

Diagnostic & Treatment

Diagnosis Path: Diagnosing spondylolisthesis in the occipito-atlanto-axial region involves a combination of clinical evaluation and imaging studies. The process typically includes:

Treatment Protocols: Treatment strategies for this condition depend on the severity of the displacement and the presence of symptoms. They may include:

Reimbursement claims with a date of service on or after October 1, 2015 require the use of ICD-10-CM codes.

Clinical Advice & FAQs

Billing Guidance

Is M43.11 a billable ICD-10 code?
Yes, M43.11 is a specific, billable code that can be used to indicate a diagnosis for reimbursement purposes.

Documentation

How do I report M43.11?
Clinical documentation must specify the nature of Spondylolisthesis, occipito-atlanto-axial region and any associated comorbidities for accurate reporting.

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