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M53.3
ICD-10-CM
Sacroiliac Dysfunction

Find information on sacroiliac joint dysfunction diagnosis, including SI joint pain, dysfunction, and inflammation. Learn about relevant medical coding (ICD-10 M54.6) and clinical documentation best practices for sacroiliac joint syndrome, sacroiliitis, and lower back pain. Explore resources for healthcare professionals addressing SI joint problems, pain management, and treatment options.

Also known as

SI Joint Dysfunction
Sacroiliac Joint Pain

Diagnosis Snapshot

Key Facts
  • Definition : Pain in the sacroiliac joint, where the spine meets the pelvis.
  • Clinical Signs : Buttock pain, low back pain, often radiating to the thigh. Pain with bending or prolonged standing.
  • Common Settings : Chiropractic, Physical Therapy, Pain Management

Related ICD-10 Code Ranges

Complete code families applicable to AAPC M53.3 Coding
M46.1

Sacroiliac joint disorders

Pain and dysfunction specifically in the sacroiliac joint.

M54.8

Other dorsalgia

Pain in the back, including the sacroiliac region, not elsewhere classified.

M53.1

Sacrococcygeal disorders

Pain and dysfunction in the area including the sacrum and coccyx.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is the sacroiliac dysfunction traumatic?

  • Yes

    Dislocation/subluxation?

  • No

    Ankylosing spondylitis related?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Sacroiliac joint pain
Lumbar spondylosis
Piriformis syndrome

Documentation Best Practices

Documentation Checklist
  • Sacroiliac joint pain location, character
  • Range of motion limitations, palpation tenderness
  • Provocative tests: FABER, Gaenslen, compression/distraction
  • Imaging findings if obtained (X-ray, MRI)
  • Diagnosis clarification: Exclude lumbar spine pathology

Coding and Audit Risks

Common Risks
  • Unspecified Laterality

    Coding sacroiliac dysfunction without specifying right, left, or bilateral can lead to claim denials and inaccurate reporting. Use ICD-10-CM codes like S33.1XXA-S33.1XXD.

  • Medical Necessity

    Lack of documentation supporting the medical necessity of procedures or therapies related to sacroiliac dysfunction may trigger audits and reimbursement issues. Ensure clear documentation linking diagnosis and treatment.

  • Specificity of Diagnosis

    Using unspecified codes like M53.1 when more specific diagnoses like ankylosing spondylitis (M45) are applicable can lead to underpayment and data integrity concerns. Proper CDI ensures accurate code assignment.

Mitigation Tips

Best Practices
  • Document SI joint pain specifics for ICD-10 M54.6 accuracy.
  • Correlate physical exam findings with imaging for M54.6 CDI.
  • Specify pain management for SI dysfunction, ensure HCC coding.
  • Query physician for SI joint laterality to optimize reimbursement.
  • For injections, document facet joint vs. SI joint distinction.

Clinical Decision Support

Checklist
  • Gaenslen's and FABER tests documented
  • Pain with palpation of SI joint noted
  • Imaging findings (X-rayMRI) reviewed
  • Consider other diagnoses (lumbar spine)
  • Assess for pain relief with SI joint injection

Reimbursement and Quality Metrics

Impact Summary
  • Sacroiliac Dysfunction Reimbursement: Coding accuracy impacts payment. Focus on ICD-10 M53.1, CPT 27096, 20550 for injections.
  • Quality Metrics Impact: Functional improvement reporting (PROMIS) influences value-based care reimbursement.
  • Coding Accuracy: Avoid unspecified codes like M53.9. Proper documentation supports medical necessity for injections.
  • Hospital Reporting: Accurate Sacroiliac Dysfunction coding affects hospital quality scores and case mix index (CMI).

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes. Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • Code SI joint pain S20.1
  • Laterality matters, use modifiers
  • Document exam findings, ROM
  • X-rays/MRI support diagnosis
  • Consider M54.6 for unspecified

Documentation Templates

Patient presents with complaints of low back pain, localized to the sacroiliac joint region, possibly radiating to the buttock, groin, or thigh.  Symptoms may include pain with weight-bearing activities, prolonged standing or sitting, and transitional movements such as rising from a chair or climbing stairs.  On physical examination, tenderness to palpation over the sacroiliac joint, positive provocation tests such as the FABER test, Gaenslen's test, or compression distraction test, and restricted range of motion in the lumbar spine may be observed.  Differential diagnosis includes lumbar disc herniation, piriformis syndrome, and hip osteoarthritis.  Diagnosis of sacroiliac joint dysfunction is based on clinical findings, with imaging such as X-ray, MRI, or CT scan generally not indicated unless there is suspicion of underlying pathology.  Treatment plan may include conservative management with physical therapy focusing on core strengthening, stretching, and mobilization of the sacroiliac joint, as well as pain management with NSAIDs, analgesics, or muscle relaxants.  Sacroiliac joint injections, including corticosteroid injections or prolotherapy, may be considered for patients who do not respond to conservative treatment.  Patient education on proper body mechanics and activity modification is crucial.  Follow-up care is recommended to monitor symptom improvement and adjust treatment as needed. The patient's prognosis for recovery from sacroiliac joint dysfunction is generally good with appropriate management.
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