Non-radiographic axial spondyloarthritis unsp site in spin

This code describes a chronic inflammatory condition primarily affecting the axial skeleton (spine and sacroiliac joints) without definitive radiographic evidence of sacroiliitis. Patients typically experience chronic back pain, stiffness, and fatigue, often worse in the morning or after inactivity, and improving with exercise. It is a form of spondyloarthritis where inflammatory changes are present but not yet visible on standard X-rays.

Assign this code when documentation confirms a diagnosis of non-radiographic axial spondyloarthritis (nr-axSpA) where the specific spinal sites affected are not specified. This diagnosis is typically made based on clinical symptoms, inflammatory markers, and imaging findings (e.g., MRI showing sacroiliitis or spinal inflammation) that do not meet the modified New York criteria for ankylosing spondylitis. Use when the provider explicitly states "non-radiographic axial spondyloarthritis" without further anatomical detail.

• Do not use this code if radiographic evidence of sacroiliitis is present; instead, consider codes for ankylosing spondylitis (M45.0-).
• Ensure the documentation clearly distinguishes between radiographic and non-radiographic forms of axial spondyloarthritis.
• If specific spinal sites are documented (e.g., cervical, thoracic, lumbar), use more specific codes from the M45.A- series.