Ankylosing Spondylitis Documentation Guide
Chronic inflammatory arthritis primarily affecting the sacroiliac joints and axial skeleton.
ICD-10 Codes: M45.0, M45.1, M45.2, M45.3, M45.4, M45.5, M45.6, M45.7, M45.8, M45.9
Common Symptoms
- Chronic low back pain
- Morning stiffness
- Reduced spinal mobility
- Enthesitis
- Fatigue
Key Documentation Elements
- BASDAI and BASFI scores
- Spinal mobility assessment (Schober, chest expansion)
- HLA-B27 status and imaging findings (sacroiliitis)
- Current therapy (NSAIDs, biologics, JAK inhibitors)
- Extra-articular manifestation screening
Documentation Challenges
- Documenting BASDAI and BASFI disease activity scores
- Recording spinal mobility measurements (Schober test)
- Capturing biologic therapy initiation and monitoring
- Tracking extra-articular manifestations (uveitis, IBD, psoriasis)
Billing Considerations
- Site-specific coding (M45.0 multiple sites through M45.9 unspecified)
- Biologic therapy administration and monitoring coding
- Complex E&M for multi-system inflammatory disease
Frequently Asked Questions
How is ankylosing spondylitis coded by site?
AS codes are site-specific: M45.0 (multiple sites), M45.1 (occipito-atlanto-axial), through M45.8 (sacral/sacrococcygeal). Scribeable maps your documented affected areas to the correct site-specific codes.
How does Scribeable track AS disease activity?
Scribeable captures BASDAI scores, spinal mobility measurements, imaging results, biologic response, and extra-articular symptoms from your encounter for comprehensive spondylitis management documentation.