ICD-10 Coding for Sacrum Pain(M54.18, M53.2X7)
Complete ICD-10-CM coding and documentation guide for Sacrum Pain. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Sacrum Pain
M54-M54.9Primary Range
Dorsalgia
This range includes codes for dorsalgia, specifically M54.18 for sacral dorsalgia.
Pain, not elsewhere classified
Includes codes for chronic pain management, relevant for chronic sacral 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 |
|---|---|---|---|
| M54.18 | Sacral dorsalgia | Use for generalized sacral pain without confirmed structural pathology. |
|
| M53.2X7 | Coccygodynia | Use when pain is specifically localized to 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 sacrum pain
Essential facts and insights about Sacrum Pain
Primary ICD-10-CM Codes for pain sacrum
Decision Criteria
clinical Criteria
- Presence of sacral tenderness and positive provocation tests.
Applicable To
- Pain localized to the sacral region
Excludes
- Low back pain (M54.5)
Clinical Validation Requirements
- Tenderness localized to sacral sulcus
- Positive Fortin finger test
Code-Specific Risks
- Risk of using unspecified codes like M54.5 instead of M54.18.
Coding Notes
- Ensure documentation specifies sacral region to avoid using more general codes.
M53.2X7 - Coccygodynia
Use when pain is specifically localized to the coccyx.
Applicable To
- Pain localized to the coccyx
Excludes
- Sacral dorsalgia (M54.18)
Clinical Validation Requirements
- Pain worsens with prolonged sitting
- Localized coccyx tenderness
Coding Notes
Ensure documentation specifies coccyx involvement.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Chronic pain
G89.21Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Sacrum Pain to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M54.18.
Impact
Clinical: May lead to inappropriate treatment., Regulatory: Non-compliance with documentation standards., Financial: Potential for claim denials.
Mitigation Strategy
Use specific anatomical terms, Include detailed physical exam findings
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding specificity requirements., Data Quality: Reduces accuracy of clinical data.
Mitigation Strategy
Use M54.18 for pain localized to the sacral region.
Impact
Audits may focus on the specificity of documented pain location.
Mitigation Strategy
Ensure detailed documentation of anatomical location and test results.
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 Sacrum Pain, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Sacrum Pain
Use these documentation templates to ensure complete and accurate documentation for Sacrum Pain. These templates include all required elements for proper coding and billing.
Chronic sacral pain management
Specialty: Pain ManagementRequired Elements
- Pain location and severity
- Duration and treatment history
- Physical exam findings
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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