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M53.3
ICD-10-CM
Sacroiliac Joint Syndrome

Find information on Sacroiliac Joint Syndrome diagnosis, including clinical documentation, medical coding, ICD-10 codes (M54.6), pain management, physical therapy, and treatment options. Learn about SI joint dysfunction symptoms, causes, and diagnostic tests for accurate healthcare coding and billing. Explore resources for medical professionals, including clinical guidelines and best practices for documenting SI joint pain and related conditions.

Also known as

SI Joint Dysfunction
Sacroiliitis
si joint syndrome
+1 more

Diagnosis Snapshot

Key Facts
  • Definition : Pain in the lower back, buttocks, or groin caused by sacroiliac joint dysfunction.
  • Clinical Signs : Buttock or lower back pain, often worse with sitting, standing, or climbing stairs. Pain can radiate to the groin, thigh, or leg.
  • Common Settings : Physical therapy, chiropractic care, pain management clinics, orthopedic clinics.

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.

M54.6

Pain in thoracic spine

Referred pain from sacroiliac issues can manifest in the thoracic spine.

M54.8

Other dorsalgia

General back pain encompassing sacroiliac pain if not specifically diagnosed.

M79.1

Myalgia

Muscle pain around the affected joint may be associated with sacroiliac syndrome.

Code-Specific Guidance

Decision Tree for

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

Is the sacroiliac joint syndrome inflammatory?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Lower back, buttock, groin pain, often radiating to leg
Degenerative disc disease causing back pain
Lumbar spine nerve root compression

Documentation Best Practices

Documentation Checklist
  • Sacroiliac joint pain location, onset
  • Fortin finger test, FABER test results
  • Palpation tenderness over SI joint
  • Pain relief with SI joint injection
  • Exclude lumbar spine, hip pathology

Coding and Audit Risks

Common Risks
  • Unspecified SI Joint Pain

    Coding with unspecified pain codes (e.g., M54.9) when more specific SI joint diagnoses are documented, impacting reimbursement and data accuracy.

  • Lack of Supporting Documentation

    Insufficient clinical documentation to support the SI joint diagnosis, leading to denials and potential compliance issues. CDI opportunity.

  • Confusing SI Joint Dysfunction

    Miscoding SI joint dysfunction with other related back pain diagnoses, affecting quality reporting and healthcare analytics.

Mitigation Tips

Best Practices
  • Document SI joint pain specifics for accurate ICD-10 coding (M46.1)
  • Correlate physical exam findings with imaging to support M46.1 diagnosis
  • Specify pain location, type, and radiation for improved CDI of SI joint dysfunction
  • Query physician for clarity if documentation lacks detail for M46.1 coding compliance
  • Review medical necessity guidelines for SI joint injections and other interventions

Clinical Decision Support

Checklist
  • Pain provocation with Fortin finger test
  • Distraction, compression, thigh thrust tests positive
  • Intraarticular SI joint injection relieves pain
  • Consider imaging (X-rayMRI) to rule out other pathologies
  • Document pain location, symptom duration, impact on ADLs

Reimbursement and Quality Metrics

Impact Summary
  • Sacroiliac Joint Syndrome: Reimbursement and Quality Metrics Impact Summary
  • Keywords: Sacroiliac joint syndrome, medical billing, ICD-10 M54.6, coding accuracy, hospital reporting, reimbursement impact, quality metrics, denials, revenue cycle management
  • Impact 1: Accurate coding (M54.6) maximizes reimbursement, avoids denials.
  • Impact 2: Proper documentation supports medical necessity for SI joint injections/procedures.
  • Impact 3: Quality metrics track pain management effectiveness and patient outcomes.
  • Impact 4: Coding errors negatively impact hospital reporting and potential penalties.

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 with M54.6
  • Laterality matters: use modifiers RT/LT
  • Document specific exam findings
  • Consider imaging/injection codes
  • Exclude lumbar spine codes if isolated SI

Documentation Templates

Patient presents with complaints of low back pain, specifically localized to the sacroiliac joint region, possibly radiating to the buttock, groin, or thigh.  The onset of pain may be related to a specific incident such as a fall, lifting heavy objects, or prolonged standing, or it may have developed gradually.  Physical examination reveals tenderness upon palpation of the sacroiliac joint, positive findings on provocative maneuvers such as the FABER test, Gaenslen's test, or compression and distraction tests.  Pain may be described as sharp, dull, aching, or stabbing and may be aggravated by activities such as walking, climbing stairs, or prolonged sitting.  Range of motion in the lumbar spine may be limited due to pain.  Differential diagnosis includes lumbar disc herniation, piriformis syndrome, and facet joint arthritis.  Diagnostic imaging, such as X-ray, MRI, or CT scan, may be considered to rule out other pathologies.  Assessment points to sacroiliac joint dysfunction, consistent with sacroiliac joint syndrome.  The treatment plan includes conservative management with physical therapy focusing on core strengthening, stretching, and range of motion exercises.  NSAIDs or other pain medications may be prescribed for pain management.  Patient education regarding proper body mechanics and activity modification will be provided.  Referral to a pain specialist or orthopedist may be considered if symptoms persist or worsen despite conservative treatment.  ICD-10 code M54.6 Sacroiliac joint pain will be used for billing purposes.