Spinal Enthesopathy

“Soft codes” are ICD-10 diagnostic codes that are difficult to objectively validate yet generate significant additional capitation. I’ve examined them here, on this blog, in my incredibly popular “Success Codes” series.


In that series, I advised you to avoid them unless you can justify their use with extensive documentation. They’re just not worth the risk of claw backs.


First, your primes figure out these codes are worth easy money, so they look for the condition and justify it through extensive documentation. Then their documentation slides a little bit, then a little bit more. Before you know it, they’re this guy,


That’s why I call the “soft codes” “traps” —they draw you in and “SNAP!” suddenly you’re wearing orange.


Spinal enthesopathy M46.02, is one such soft code. It refers to inflammation of the tendons at the points of their origins and insertions as well ligaments where they come off the bone.


It’s usually associated with autoimmune disease such as Ankylosing Spondylitis and as such it’s a risk code, one that can increase your monthly capitation by nearly 30%. There are no objective methods of confirming the diagnosis, it’s solely clinical.


It’s meant to be an unusual diagnosis as well, as rarely made as Ankylosing Spondylitis itself—if not less so.


Not understanding this last fact cost a national Medicare Advantage organization almost $300m in claw backs and punitive fines this past month, though they were able to get away without admitting any wrongdoing.


Not only did they inappropriately increase their revenue with this code, allegedly submitting it when it wasn’t supported in the documentation, but based on their own internal audits, they knew they were over-coding and didn’t correct their submissions.




Such over-coding is obvious with a simple statistical analysis of your patient panel.


Your tactic for success?


  • Avoid codes like these unless you can justify the diagnosis with extensive documentation.


  • Don’t allow your staff to submit them unless that documentation is there.


  • And nip any over-coding in the bud., internally.


If you don’t, it could cost you millions—or worse.