ICD-10 Coding for Buttocks Pain(M54.30, G57.01, R10.2)
Complete ICD-10-CM coding and documentation guide for Buttocks Pain. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Buttocks Pain
M54.3-M54.5Primary Range
Dorsalgia, including sciatica and low back pain
Covers primary codes for sciatica and low back pain, which are common causes of buttocks pain.
Mononeuropathies of lower limb, including piriformis syndrome
Includes piriformis syndrome, a specific cause of buttocks pain.
Pelvic and perineal pain
Used for localized pelvic pain without radiation, relevant for certain presentations of buttocks pain.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| M54.30 | Sciatica, unspecified side | Use when sciatica is diagnosed without specifying laterality. |
|
| G57.01 | Piriformis syndrome, right side | Use when piriformis syndrome is confirmed with positive FAIR test. |
|
| R10.2 | Pelvic and perineal pain | Use for pain localized to the pelvic region without radiation. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for buttocks pain
Essential facts and insights about Buttocks Pain
Primary ICD-10-CM Codes for buttocks pain
Decision Criteria
clinical Criteria
- Presence of radicular pain and neurological deficits.
Applicable To
- Radicular pain from lumbar spine to buttock/leg
Excludes
- Piriformis syndrome (G57.0-)
Clinical Validation Requirements
- Pain radiating from lumbar spine to buttock/leg
- Neurological deficits present
Code-Specific Risks
- Misclassification if laterality is not documented.
Coding Notes
- Ensure documentation specifies radiation and neurological involvement.
G57.01 - Piriformis syndrome, right side
Use when piriformis syndrome is confirmed with positive FAIR test.
Applicable To
- Pain in sciatic notch
- Positive FAIR test
Excludes
- Sciatica (M54.3-)
Clinical Validation Requirements
- Tenderness over sciatic notch
- Pain reproduced with FAIR maneuver
- No neurological deficits
Coding Notes
Document FAIR test results and absence of neurological deficits.
R10.2 - Pelvic and perineal pain
Use for pain localized to the pelvic region without radiation.
Applicable To
- Localized pelvic pain without radiation
Excludes
- Low back pain (M54.5)
Clinical Validation Requirements
- Localized pelvic tenderness
- No radiation beyond groin
Coding Notes
Ensure pain is localized to the pelvic region.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Buttocks Pain to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M54.30.
Impact
Clinical: Inaccurate clinical data representation., Regulatory: Non-compliance with ICD-10 coding rules., Financial: Potential claim denials or incorrect reimbursement.
Mitigation Strategy
Always specify right or left side in documentation., Use templates to ensure completeness.
Impact
Reimbursement: Incorrect DRG assignment may occur., Compliance: Non-compliance with ICD-10 guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Use M54.3- or G57.0- for radicular pain.
Impact
Failure to document laterality can lead to coding errors.
Mitigation Strategy
Implement documentation checks for laterality.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Buttocks Pain, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Buttocks Pain
Use these documentation templates to ensure complete and accurate documentation for Buttocks Pain. These templates include all required elements for proper coding and billing.
Physical Therapy Progress Note
Specialty: Physical TherapyRequired Elements
- Pain location and severity
- Radiation and aggravating factors
- Physical exam findings
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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