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
Sacroiliac joint disorders
Pain and dysfunction specifically in the sacroiliac joint.
Pain in thoracic spine
Referred pain from sacroiliac issues can manifest in the thoracic spine.
Other dorsalgia
General back pain encompassing sacroiliac pain if not specifically diagnosed.
Myalgia
Muscle pain around the affected joint may be associated with sacroiliac syndrome.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the sacroiliac joint syndrome inflammatory?
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 |
Coding with unspecified pain codes (e.g., M54.9) when more specific SI joint diagnoses are documented, impacting reimbursement and data accuracy.
Insufficient clinical documentation to support the SI joint diagnosis, leading to denials and potential compliance issues. CDI opportunity.
Miscoding SI joint dysfunction with other related back pain diagnoses, affecting quality reporting and healthcare analytics.
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.