Spondylosis w/o myelopathy or radiculopathy, thoracic region

This code describes degenerative changes of the thoracic spine, such as osteophytes and disc space narrowing, that are not causing compression of the spinal cord (myelopathy) or nerve roots (radiculopathy). It indicates the presence of age-related wear and tear in the mid-back without neurological compromise.

Use this code when documentation specifies spondylosis affecting the thoracic spine, and explicitly states the absence of myelopathy or radiculopathy. This is appropriate for patients presenting with thoracic back pain attributed to degenerative changes, but without signs or symptoms of nerve involvement. Documentation should clearly localize the spondylosis to the thoracic region.

• Ensure documentation explicitly rules out myelopathy and radiculopathy; otherwise, a more specific code is warranted.
• Do not use this code if the spondylosis is specified as affecting other spinal regions (e.g., cervical, lumbar).
• Consider sequencing this code after a pain diagnosis (e.g., M54.6) if the spondylosis is the underlying cause of the patient's thoracic back pain.