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
Sacroiliac joint disorders
Pain and other problems affecting the sacroiliac joint.
Pain in thoracic spine
Pain localized to the thoracic region of the back.
Other dorsalgia
Pain in the back, not otherwise specified, excluding lower back.
Pain in joint, pelvic region and thigh
Joint pain affecting the pelvis and thigh area, including hip.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the sacroiliac joint pain due to trauma/fracture?
When to use each related code
| Description |
|---|
| Sacroiliac joint pain |
| Lumbosacral sprain/strain |
| Piriformis syndrome |
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.
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.
Confusing SI joint pain (M54) with SI joint dysfunction/derangement (S33), leading to incorrect coding. Relevant for CDI and HCC coding for risk adjustment.
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).