Learn about sacral insufficiency fracture diagnosis, including clinical documentation, ICD-10 code S32.1XXA, medical coding guidelines, and healthcare best practices. Find information on symptoms, imaging (X-ray, MRI, CT), treatment, and recovery for sacral stress fractures. This resource offers guidance for physicians, coders, and other healthcare professionals on accurate documentation and coding of sacral insufficiency fractures.
Also known as
Disorders of bone density and structure
Includes osteoporosis and other bone density disorders, often related to fractures.
Fracture of sacrum and coccyx
Covers fractures specifically in the sacral and coccygeal region.
Spondylopathies
Encompasses various spinal disorders which may contribute to sacral insufficiency.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the sacral insufficiency fracture traumatic?
Yes
Code a traumatic fracture of the sacrum (e.g., S22.0XXA, S22.1XXA). Refer to guidelines for specific location and laterality.
No
Is the fracture pathological?
When to use each related code
| Description |
|---|
| Sacral Insufficiency Fracture |
| Osteoporotic Vertebral Fracture |
| Pelvic Stress Fracture |
Coding with unspecified trauma codes (e.g., S32.009A) without proper documentation of traumatic event raises audit risk.
Incorrectly coding osteoporosis (M80.-) as the principal diagnosis instead of sacral insufficiency fracture (S32.1-) if the fracture is the reason for encounter.
Lacking specific documentation supporting the diagnosis of sacral insufficiency fracture (e.g., imaging, symptoms) leading to coding errors and denials.
SUBJECTIVE: Patient presents with complaints of insidious onset low back pain, localized to the sacral region, possibly radiating to the buttocks or groin. Pain is often described as dull, aching, and may be worse with weight-bearing, prolonged standing, or transfers. The patient denies any specific trauma or fall. Past medical history may include osteoporosis, osteopenia, or other conditions associated with decreased bone density. Medications may include bisphosphonates, calcium, and vitamin D supplements. Surgical history may be significant for prior pelvic surgery. Review of systems is otherwise unremarkable. OBJECTIVE: Physical examination reveals tenderness to palpation over the sacrum. Neurological examination is typically normal, although some patients may exhibit mild sensory changes or weakness in the lower extremities. Range of motion in the lumbar spine may be limited due to pain. Gait may be antalgic. Imaging studies, including plain radiographs, may be inconclusive in early stages. MRI or bone scintigraphy (bone scan) with SPECTCT are often utilized to confirm the diagnosis of sacral insufficiency fracture. DEXA scan may be performed to assess bone mineral density. ASSESSMENT: Sacral insufficiency fracture. Differential diagnosis includes lumbar spine degenerative disc disease, sacroiliac joint dysfunction, piriformis syndrome, and other causes of low back pain. Diagnosis is based on the combination of patient history, physical exam findings, and imaging results. PLAN: Conservative management is the mainstay of treatment for sacral insufficiency fracture. This includes pain management with analgesics, such as acetaminophen or NSAIDs. Weight-bearing restrictions and activity modification are essential to promote fracture healing. Physical therapy may be prescribed to improve mobility and strength. Bisphosphonate therapy is often initiated to address underlying osteoporosis or osteopenia. Patient education regarding fall prevention and bone health is crucial. Close follow-up is recommended to monitor symptom resolution and fracture healing. Surgical intervention is rarely necessary, reserved for cases of nonunion or severe pain refractory to conservative measures. Referral to an orthopedic specialist or physiatrist may be warranted for further evaluation and management.