Intervertebral disc disorders w myelopathy, thoracic region

This code signifies a thoracic intervertebral disc disorder that is causing compression of the spinal cord, leading to neurological deficits. Myelopathy in this context refers to functional disturbances and/or pathological changes in the spinal cord due to the disc pathology.

Apply this code when documentation clearly indicates a thoracic disc herniation, protrusion, or degeneration is directly responsible for symptoms of myelopathy, such as gait disturbance, weakness, spasticity, or sensory changes below the level of the lesion. Supporting documentation would include neurological exam findings, imaging (MRI) confirming spinal cord compression, and a physician's explicit diagnosis of myelopathy due to a thoracic disc disorder.

• Ensure the documentation explicitly links the thoracic disc disorder to the myelopathy; do not assume causation.
• Do not use this code for radiculopathy alone; a separate code for thoracic radiculopathy (M54.14) would be more appropriate if myelopathy is not present.
• Sequence this code as the primary diagnosis when the myelopathy is the chief complaint or reason for the encounter.