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M41.9
ICD-10-CM
Levoscoliosis

Understanding levoscoliosis diagnosis, coding, and documentation? Find information on left curve scoliosis, levoscoliosis ICD-10 codes (M41), spinal curvature to the left, levoscoliosis treatment, and clinical documentation requirements for accurate medical coding and billing. Learn about levoscoliosis symptoms, diagnosis confirmation, and radiological findings for optimal healthcare practices.

Also known as

Leftward spinal curvature
Left scoliosis

Diagnosis Snapshot

Key Facts
  • Definition : Leftward curvature of the spine.
  • Clinical Signs : Uneven shoulders, hips, prominent rib cage, back pain.
  • Common Settings : School screenings, pediatrician office, orthopedic clinic.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC M41.9 Coding
M41

Scoliosis

Abnormal lateral curvature of the spine.

Q76.2

Congenital scoliosis due to bony malformation

Scoliosis present at birth due to bone abnormalities.

M41.0

Infantile idiopathic scoliosis

Scoliosis of unknown cause developing before age 3.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is the levoscoliosis thoracic?

  • Yes

    Is there a specified site?

  • No

    Is the levoscoliosis thoracolumbar?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Left curve of the spine
Right curve of the spine
Lateral curve of spine

Documentation Best Practices

Documentation Checklist
  • Levoscoliosis diagnosis confirmed by physical exam and imaging.
  • Specify Cobb angle measurement from radiographic imaging.
  • Document curve location (e.g., thoracic, lumbar).
  • Note any associated symptoms (e.g., pain, dyspnea).
  • ICD-10-CM code (e.g., M41.02, M41.12) documented.

Coding and Audit Risks

Common Risks
  • Laterality Coding Error

    Incorrectly coding right scoliosis (dextroscoliosis) as levoscoliosis or vice-versa, leading to inaccurate claims.

  • Unspecified Scoliosis

    Failing to document the specific spinal region affected (e.g., thoracic, lumbar) resulting in coding for unspecified scoliosis.

  • Severity Miscoding

    Lack of documentation specifying the degree of curvature may lead to inaccurate severity coding and improper reimbursement.

Mitigation Tips

Best Practices
  • Code C76.10 for unspecified levoscoliosis, C76.11-C76.13 for specific regions.
  • Document curve degree, Cobb angle, and skeletal maturity for accurate coding.
  • Query physician for clarity if documentation lacks laterality (left vs. right).
  • Regularly audit levoscoliosis documentation for CDI and compliance.
  • Use standardized terminology like "levoconvex" for consistent documentation.

Clinical Decision Support

Checklist
  • Confirm leftward spinal curvature on imaging (ICD-10 M41)
  • Assess Cobb angle for severity documentation (SNOMED CT 298382003)
  • Rule out other etiologies (e.g., neuromuscular) patient safety
  • Document curve convexity, apex, and rotation for clarity

Reimbursement and Quality Metrics

Impact Summary
  • Levoscoliosis reimbursement hinges on accurate ICD-10 coding (M41) and appropriate modifier use for optimal payment.
  • Coding quality directly impacts levoscoliosis case mix index (CMI) accuracy for hospital reporting and resource allocation.
  • Physician documentation specificity for levoscoliosis severity and curve measurement influences appropriate billing levels.
  • Accurate levoscoliosis coding ensures proper reflection of patient acuity and resource utilization for performance metrics.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes for . Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • Code M41.12 for levoscoliosis
  • Document curve convexity left
  • Specify thoracic/lumbar location
  • Add laterality to scoliosis codes
  • Query physician if unspecified

Documentation Templates

Patient presents with levoscoliosis, a left curvature of the spine.  Clinical examination reveals a lateral spinal curvature with the apex deviating to the left.  Assessment includes observation of postural asymmetry,  spinal range of motion evaluation, and Adam's forward bend test.  Radiographic imaging, specifically standing PA and lateral spinal X-rays, confirms the diagnosis of levoscoliosis and quantifies the Cobb angle.  Differential diagnoses considered include postural scoliosis, neuromuscular scoliosis, and congenital scoliosis.  Severity of the curve, patient age, skeletal maturity, and presence of pain are factors influencing the treatment plan.  Treatment options for levoscoliosis may include observation, bracing, physical therapy, and in severe cases, spinal fusion surgery.  Patient education regarding scoliosis progression, bracing protocols, and exercises for scoliosis management is provided.  Follow-up appointments are scheduled for monitoring curve progression and evaluating treatment efficacy.  ICD-10 codes M41.0 and M41.1 are considered for coding this levoscoliosis diagnosis based on the location and severity.  Medical billing will reflect the evaluation and management codes corresponding to the complexity of the patient encounter.  The patient demonstrates understanding of the diagnosis, treatment plan, and potential complications.  Prognosis depends on the severity of the curve and adherence to the prescribed treatment plan.