ICD-10 Coding for Coccydynia(M53.3, S32.2XXA)
Complete ICD-10-CM coding and documentation guide for Coccydynia. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Coccydynia
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| M53.3 | Sacrococcygeal disorders, not elsewhere classified | Use when the patient presents with chronic tailbone pain without evidence of fracture. |
|
| S32.2XXA | Fracture of coccyx, initial encounter | Use when coccydynia is due to a traumatic fracture of the coccyx. |
|
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 coccydynia
Essential facts and insights about Coccydynia
Primary ICD-10-CM Codes for coccydynia
Decision Criteria
clinical Criteria
- Chronic pain localized to the coccyx with no fracture
documentation Criteria
- Imaging results confirming no fracture
Applicable To
- Coccydynia
- Coccygodynia
Excludes
- Fracture of coccyx (S32.2)
Clinical Validation Requirements
- Localized tenderness over coccyx
- Pain duration greater than 3 months
- Imaging results (X-ray/MRI) confirming no fracture
Code-Specific Risks
- Misclassification if trauma is involved without proper documentation
Coding Notes
- Ensure documentation specifies chronicity and excludes fractures.
S32.2XXA - Fracture of coccyx, initial encounter
Use when coccydynia is due to a traumatic fracture of the coccyx.
Clinical Validation Requirements
- History of trauma
- Imaging confirming fracture
Coding Notes
Ensure proper sequencing with trauma codes.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Fracture of coccyx, initial encounter
S32.2XXADocumentation & Coding Risks
Avoid these common documentation and coding issues when documenting Coccydynia to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M53.3.
Impact
Clinical: Misleading clinical picture, Regulatory: Non-compliance with coding standards, Financial: Potential claim denials
Mitigation Strategy
Always verify and document trauma history, Use imaging to confirm fractures
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate medical records.
Mitigation Strategy
Use CPT 20605 for sacrococcygeal joint injections.
Impact
Failure to sequence trauma codes before M53.3 when applicable.
Mitigation Strategy
Ensure trauma is documented and sequenced first.
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 Coccydynia, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Coccydynia
Use these documentation templates to ensure complete and accurate documentation for Coccydynia. These templates include all required elements for proper coding and billing.
Chronic coccydynia without trauma
Specialty: OrthopedicsRequired Elements
- Pain duration
- Physical exam findings
- Imaging results
- Treatment history
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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