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
Pain in sacroiliac region
Pain localized to the sacroiliac joint.
Sprain of sacroiliac joint
Traumatic stretching or tearing of sacroiliac ligaments.
Sacroiliitis, not elsewhere classified
Inflammation of the sacroiliac joint, unspecified cause.
Other biomechanical lesions
May include sacroiliac dysfunction not classified elsewhere.
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?
When to use each related code
Description |
---|
Sacroiliac pain |
Lumbosacral sprain/strain |
Pirifomis syndrome |
Using unspecified codes (e.g., M54.9) when more specific sacroiliac joint pain diagnoses are documented, impacting reimbursement and data accuracy.
Miscoding lumbar spine pain (e.g., M54.5) as sacroiliac joint pain (e.g., M54.6), leading to incorrect treatment plans and claims.
Missing documentation of right, left, or bilateral sacroiliac joint involvement, hindering accurate coding and potentially impacting medical necessity reviews.
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.