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M53.3
ICD-10-CM
Sacroiliac Pain

Find information on sacroiliac joint pain diagnosis, including SI joint dysfunction, SI joint pain symptoms, and treatment. Learn about relevant ICD-10 codes (M54.6, S33.1), medical coding for sacroiliac pain, and proper clinical documentation for healthcare professionals. Explore resources for sacroiliac joint inflammation, sacroiliitis, and lower back pain differential diagnosis related to the sacroiliac joint. This resource helps with accurate diagnosis and coding of sacroiliac pain conditions.

Also known as

SI Joint Pain
Sacroiliac Joint Dysfunction
SIJ Pain

Diagnosis Snapshot

Key Facts
  • Definition : Pain in the lower back or buttocks, often radiating to the thigh, caused by sacroiliac joint dysfunction.
  • Clinical Signs : Pain with palpation of the SI joint, positive SI joint provocation tests, limited range of motion.
  • Common Settings : Physical therapy, chiropractic care, pain management clinics.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC M53.3 Coding
M54.6

Pain in sacroiliac region

Pain localized to the sacroiliac joint.

S33.1XXA

Sprain of sacroiliac joint

Traumatic stretching or tearing of sacroiliac ligaments.

M46.1

Sacroiliitis, not elsewhere classified

Inflammation of the sacroiliac joint, unspecified cause.

M99.8X

Other biomechanical lesions

May include sacroiliac dysfunction not classified elsewhere.

Code-Specific Guidance

Decision Tree for

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

Is the sacroiliac pain inflammatory?

  • Yes

    Related to Ankylosing Spondylitis?

  • No

    Is the pain due to degeneration/osteoarthritis?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Sacroiliac pain
Lumbosacral sprain/strain
Pirifomis syndrome

Documentation Best Practices

Documentation Checklist
  • Sacroiliac pain diagnosis documented
  • Laterality specified (right, left, bilateral)
  • Symptom onset, duration, characteristics
  • Physical exam findings supporting SI joint dysfunction
  • Diagnostic tests performed/results (if applicable)

Coding and Audit Risks

Common Risks
  • Unspecified SI Pain Code

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

  • SI Joint vs. Lumbar Spine

    Miscoding lumbar spine pain (e.g., M54.5) as sacroiliac joint pain (e.g., M54.6), leading to incorrect treatment plans and claims.

  • Lacking Laterality Documentation

    Missing documentation of right, left, or bilateral sacroiliac joint involvement, hindering accurate coding and potentially impacting medical necessity reviews.

Mitigation Tips

Best Practices
  • Document SI joint tenderness, gait, and pain radiation for accurate ICD-10 coding (M54.6).
  • Correlate physical exam findings (e.g., FABER, Gaenslen's tests) with imaging for CDI of SI joint dysfunction.
  • Specify pain duration and location to support medical necessity for injections and ensure payer compliance.
  • Query physician for clarity if documentation lacks detail for proper coding and billing of SI joint interventions.
  • Use standardized terminology (e.g., sacroiliitis vs. SI joint pain) for consistent clinical documentation and reporting.

Clinical Decision Support

Checklist
  • Confirm pain location: Sacroiliac joint region
  • Assess range of motion: Positive SI joint provocation tests
  • Imaging findings: Rule out other pathologies (XrayMRI)
  • Consider injection response: Diagnostic block relief

Reimbursement and Quality Metrics

Impact Summary
  • Sacroiliac Pain Reimbursement: Coding accuracy impacts payments. Focus on M54.6, S33.5XXA, and laterality for optimal reimbursement.
  • Quality Metrics Impact: Accurate sacroiliac pain diagnosis coding affects hospital quality reporting and value-based care.
  • Coding Accuracy: Avoid unspecified codes. Proper documentation supports medical necessity and reduces denials.
  • Hospital Reporting: Precise coding improves data analysis for resource allocation and patient outcomes tracking.

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 specifically
  • Laterality: Document left/right/bilateral
  • Consider imaging confirmation for M54.6
  • Exclude lumbar spine as primary cause
  • Check guidelines for injection coding

Documentation Templates

Patient presents with complaints of low back pain, specifically localized to the sacroiliac joint region.  Symptoms include pain in the buttock, lower back, and may radiate to the groin, thigh, or hip.  Onset of sacroiliac joint pain is described as insidious or may be related to a specific incident such as a fall or lifting injury.  Pain is aggravated by activities such as prolonged standing, walking, climbing stairs, or transitional movements like getting in and out of a car.  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.  Differential diagnosis includes lumbar disc herniation, sciatica, piriformis syndrome, and hip osteoarthritis.  Diagnostic imaging such as X-ray, MRI, or CT scan may be considered to rule out other pathologies.  Assessment: Sacroiliac joint dysfunction, right greater than left.  Plan: Conservative management including physical therapy focusing on core strengthening exercises, stretching, and stabilization techniques.  Patient education on proper body mechanics and activity modification.  Consider NSAIDs for pain management.  Referral to pain management specialist if symptoms persist or worsen.  Follow-up scheduled in two weeks to assess response to treatment.