Non-radiographic axial spondyloarthritis of thrclm region

This code describes a chronic inflammatory condition primarily affecting the spine and sacroiliac joints, specifically in the thoracic and lumbar regions, where characteristic changes are not yet visible on conventional X-rays. Patients typically experience persistent back pain, stiffness, and fatigue, often worse in the morning or after inactivity. It is part of the spectrum of spondyloarthritis, distinguished by the absence of definitive radiographic damage.

Use this code for patients diagnosed with non-radiographic axial spondyloarthritis (nr-axSpA) when the primary affected region is the thoracolumbar spine. This diagnosis is typically made based on clinical symptoms, inflammatory markers, and imaging findings from MRI showing active inflammation in the sacroiliac joints or spine, in the absence of definitive radiographic sacroiliitis. Documentation should clearly specify the non-radiographic nature and the thoracolumbar involvement.

• Ensure documentation explicitly states "non-radiographic" and specifies the "thoracolumbar region" to support this code.
• Do not use this code if radiographic evidence of sacroiliitis or spinal changes consistent with ankylosing spondylitis is present; instead, use codes from the M45.0-M45.9 series.
• Consider sequencing this code as the primary diagnosis when it is the main reason for the encounter, followed by codes for associated symptoms or complications.