Facebook tracking pixel
M53.3
ICD-10-CM
Sacroiliac Joint Pain

Find information on sacroiliac joint pain diagnosis, including clinical documentation, medical coding (ICD-10 M54.6, CPT codes), and healthcare resources. Learn about SI joint dysfunction, sacrum pain, lower back pain diagnosis, buttock pain, and posterior pelvic pain assessment. This resource helps healthcare professionals accurately document and code sacroiliac joint conditions for proper reimbursement and patient care. Explore symptoms, causes, and treatment options for SI joint pain.

Also known as

SI Joint Pain
SIJ Pain
Sacroiliac Dysfunction
+2 more

Diagnosis Snapshot

Key Facts
  • Definition : Pain in the sacroiliac joints, which connect the spine to the pelvis.
  • Clinical Signs : Lower back, buttock, or groin pain; stiffness; pain with movement or prolonged sitting.
  • Common Settings : Physical therapy, chiropractic care, pain management clinics.

Related ICD-10 Code Ranges

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

Sacroiliac joint disorders

Pain and other problems affecting the sacroiliac joint.

M54.6

Pain in thoracic spine

Pain localized to the thoracic region of the back.

M54.8

Other dorsalgia

Pain in the back, not otherwise specified, excluding lower back.

M25.5

Pain in joint, pelvic region and thigh

Joint pain affecting the pelvis and thigh area, including hip.

Code-Specific Guidance

Decision Tree for

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

Is the sacroiliac joint pain due to trauma/fracture?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Sacroiliac joint pain
Lumbosacral sprain/strain
Piriformis syndrome

Documentation Best Practices

Documentation Checklist
  • Sacroiliac joint pain diagnosis documented
  • Laterality specified (right, left, or bilateral)
  • Symptom onset, duration, and characteristics
  • Physical exam findings supporting SI joint dysfunction
  • Imaging results if obtained (X-ray, MRI, CT)

Coding and Audit Risks

Common Risks
  • Unspecified SI Joint Pain

    Coding with unspecified codes (e.g., M54.9) when more specific diagnoses are documented, impacting reimbursement and data accuracy. Relevant for medical coding audits and CDI.

  • SI Joint Pain Laterality

    Missing documentation of laterality (right, left, bilateral) for SI joint pain (e.g., M54.21, M54.22, M54.29). Impacts coding accuracy and healthcare compliance.

  • SI Joint Pain vs. Dysfunction

    Confusing SI joint pain (M54) with SI joint dysfunction/derangement (S33), leading to incorrect coding. Relevant for CDI and HCC coding for risk adjustment.

Mitigation Tips

Best Practices
  • Document SI joint pain specifics for ICD-10 M54.6 accuracy.
  • Correlate exam findings with imaging (X-ray, MRI) for CDI of M54.6.
  • Rule out lumbar spine pathology for accurate SI joint diagnosis coding.
  • Specify pain location, radiation, and type for optimal medical coding compliance.
  • Consider physical therapy referral and document response for improved care and coding.

Clinical Decision Support

Checklist
  • Pain localized to SI joint ICD-10: M54.6
  • Fortin finger test positive Document palpation findings
  • FABER or Gaenslen test positive Improve diagnostic accuracy
  • Consider imaging if red flags present Patient safety priority

Reimbursement and Quality Metrics

Impact Summary
  • Sacroiliac Joint Pain: Coding accuracy impacts reimbursement for injections, radiofrequency ablation, and surgery.
  • Proper ICD-10 (e.g., M54.6) and CPT coding maximizes SI joint pain procedure reimbursement.
  • Accurate SI joint pain diagnosis reporting improves quality metrics and patient outcomes tracking.
  • Timely documentation and coding of SI joint dysfunction minimizes claim denials and optimizes revenue cycle.

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 laterality
  • Document SI joint dysfunction specifics
  • ICD-10 M46.1 for SI joint inflammation
  • Consider M54.6 for SI subluxation
  • Use modifiers for injections/procedures

Documentation Templates

Patient presents with complaints of low back pain, specifically localized to the sacroiliac joint region.  The onset of pain is described as (acuteinsidiousgradual) and began (duration) ago.  Patient reports the pain as (sharpdullthrobbingachingburning) and (constantintermittent), with radiation to the (buttocks, groin, thigh, leg) noted.  Aggravating factors include (prolonged standing, sitting, walking, bending, twisting, climbing stairs, transitioning from sit to stand).  Alleviating factors include (rest, ice, heat, over-the-counter pain relievers such as ibuprofen or naproxen).  Physical examination reveals tenderness to palpation over the sacroiliac joint, positive findings on provocative maneuvers such as the FABER test, compression test, distraction test, and Gaenslen's test.  Range of motion in the lumbar spine is (limitednormal) with pain noted upon (flexion, extension, lateral bending, rotation).  Neurological examination of the lower extremities is unremarkable.  Differential diagnoses considered include lumbar radiculopathy, degenerative disc disease, piriformis syndrome, and facet joint pain.  Based on the patient's history, physical examination findings, and clinical presentation, the diagnosis of sacroiliac joint pain is established.  Treatment plan includes conservative management with physical therapy focusing on strengthening core muscles and improving flexibility, NSAIDs for pain relief, and activity modification.  Patient education regarding proper body mechanics and posture provided.  Follow-up scheduled in (duration) to assess response to treatment.  If symptoms persist or worsen, consider referral to a pain specialist or orthopedist for further evaluation and management, including potential corticosteroid injections or radiofrequency ablation.  ICD-10 code: M54.81 (Sacroiliac joint pain).
Sacroiliac Joint Pain - AI-Powered ICD-10 Documentation