ICD-10 Coding for Sacrococcygeal Pain(M53.3, M53.82)
Complete ICD-10-CM coding and documentation guide for Sacrococcygeal Pain. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Sacrococcygeal Pain
M53.3-M53.83Primary Range
Other and unspecified dorsopathies
This range includes codes for sacrococcygeal disorders, which are primary for sacrococcygeal pain.
Pain, not elsewhere classified
These codes are used for pain management scenarios related to sacrococcygeal 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 |
|---|---|---|---|
| M53.3 | Sacrococcygeal disorders, not elsewhere classified | Use when documentation specifies localized sacrococcygeal pain without evidence of fracture or neoplasm. |
|
| M53.82 | Other specified disorders of sacrum | Use when dynamic radiographs confirm hypermobility and pain relief is achieved through guided injections. |
|
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 sacrococcygeal pain
Essential facts and insights about Sacrococcygeal Pain
Primary ICD-10-CM Codes for sacrococcygeal pain
Decision Criteria
clinical Criteria
- Pain localized to sacrococcygeal junction without fracture
Applicable To
- Localized sacrococcygeal pain
Excludes
- Fracture of coccyx
- Neoplasm of coccyx
Clinical Validation Requirements
- Tenderness localized to sacrococcygeal junction
- No evidence of fracture or neoplasm
- Pain exacerbated by sitting >30 minutes
Code-Specific Risks
- Misclassification if fracture or neoplasm is present
Coding Notes
- Ensure documentation clearly states the absence of fracture or neoplasm.
M53.82 - Other specified disorders of sacrum
Use when dynamic radiographs confirm hypermobility and pain relief is achieved through guided injections.
Applicable To
- Sacrococcygeal hypermobility
Excludes
- Spondylolisthesis of sacrum
Clinical Validation Requirements
- Dynamic radiographs show >25° coccygeal mobility
- Ultrasound-guided injection provides >50% pain relief
Coding Notes
Ensure radiographic evidence supports hypermobility diagnosis.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Sacrococcygeal Pain to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M53.3.
Impact
Clinical: Misdiagnosis of sacrococcygeal disorders., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials.
Mitigation Strategy
Ensure dynamic radiographs are performed, Document radiographic findings clearly
Impact
Reimbursement: Incorrect coding may lead to claim denials., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Query provider to clarify if pain is generalized or specific to sacrococcygeal junction.
Impact
Incorrect sequencing of G89 codes for pain management.
Mitigation Strategy
Ensure G89 codes are sequenced first when pain management is the primary reason for the encounter.
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 Sacrococcygeal Pain, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Sacrococcygeal Pain
Use these documentation templates to ensure complete and accurate documentation for Sacrococcygeal Pain. These templates include all required elements for proper coding and billing.
Chronic Sacrococcygeal Pain
Specialty: OrthopedicsRequired Elements
- Pain severity and 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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