Find information on SI joint pain diagnosis, including clinical documentation tips, ICD-10 codes (S33.1, M54.6), medical coding guidelines, and healthcare provider resources. Learn about sacroiliac joint dysfunction, pain management, and treatment options. Explore accurate diagnosis criteria and documentation best practices for SI joint pain.
Also known as
Pain in joint involving lower back
Pain localized to the sacroiliac joint.
Sprain and strain of sacroiliac joint
Injury to the sacroiliac ligaments causing pain.
Pain in thoracic spine
Referred pain from SI joint issues felt in the upper back.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the SI joint pain traumatic?
Yes
Dislocation/subluxation?
No
Is there inflammation?
When to use each related code
Description |
---|
Sacroiliac joint pain |
Lumbosacral sprain/strain |
Piriformis syndrome |
Coding M54.9 (Unspecified SI joint pain) when more specific diagnoses like inflammation or osteoarthritis are documented, impacting reimbursement and data accuracy.
Misdiagnosis between SI joint pain and lumbar spine conditions can lead to incorrect codes (e.g., M54 vs. M40-M54), affecting quality metrics.
Missing documentation specifying right, left, or bilateral SI joint involvement necessitates defaulting to unspecified codes, hindering accurate tracking and trending.
Patient presents with complaints consistent with sacroiliac (SI) joint pain. Onset of pain is described as [onset: e.g., gradual, sudden], located in the [location: e.g., lower back, buttock, groin, thigh], and characterized as [character: e.g., sharp, dull, aching, throbbing]. Pain is [exacerbating factors: e.g., aggravated by prolonged standing, sitting, bending, twisting, walking, climbing stairs] and [relieving factors: e.g., relieved by rest, ice, heat, medication]. Patient denies [associated symptoms: e.g., numbness, tingling, weakness, bowel or bladder dysfunction] radiating down the leg. Physical examination reveals [physical exam findings: e.g., tenderness to palpation over the SI joint, positive FABER test, positive Gaenslen's test, limited lumbar range of motion]. Differential diagnosis includes lumbar radiculopathy, piriformis syndrome, and hip osteoarthritis. Assessment: Sacroiliac joint dysfunction (ICD-10 code: M53.1). Plan: Conservative management including [treatment plan: e.g., physical therapy focusing on core strengthening and stabilization exercises, NSAIDs for pain relief, SI joint belt for support, patient education on proper body mechanics]. Follow-up scheduled in [duration: e.g., 2 weeks] to assess response to treatment. Consider referral to pain management specialist or orthopedist if symptoms persist or worsen.