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ICD-10 Coding for Sacroiliac Joint Dysfunction(M53.3, M46.1, S33.6XXA)

Complete ICD-10-CM coding and documentation guide for Sacroiliac Joint Dysfunction. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

SI Joint DysfunctionSacroiliac Joint PainSIJ Dysfunctionsi joint painsacroiliac pain

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Related ICD-10 Code Ranges

Complete code families applicable to Sacroiliac Joint Dysfunction

M53-M54Primary Range

Other dorsopathies

This range includes codes for non-inflammatory sacroiliac joint dysfunction and related back pain conditions.

M46

Inflammatory spondylopathies

This range includes codes for inflammatory sacroiliitis, which requires imaging confirmation.

S33

Dislocation and sprain of joints and ligaments of lumbar spine and pelvis

This range includes codes for acute traumatic injuries to the sacroiliac joint.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
M53.3Sacroiliac joint dysfunction, non-inflammatoryUse when clinical diagnosis confirms non-inflammatory SI joint dysfunction without imaging evidence of inflammation.
  • Positive Fortin test
  • Three positive provocative tests
  • Imaging excludes inflammatory changes
M46.1Sacroiliitis, not elsewhere classifiedUse when imaging confirms inflammatory changes in the sacroiliac joint.
  • CRP >5 mg/L
  • Bilateral SI edema on MRI
S33.6XXASprain of sacroiliac joint, initial encounterUse for acute traumatic injuries to the sacroiliac joint.
  • Mechanism of injury documented
  • Edema on ultrasound

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 sacroiliac joint dysfunction

Essential facts and insights about Sacroiliac Joint Dysfunction

The ICD-10 code for non-inflammatory sacroiliac joint dysfunction is M53.3, used when clinical tests confirm the condition without imaging evidence of inflammation.

Primary ICD-10-CM Codes for sacroiliac joint dysfunction

M53.3
Sacroiliac joint dysfunction, non-inflammatory
Billable Code

Decision Criteria

clinical Criteria

  • Positive Fortin test and three positive provocative tests

documentation Criteria

  • Imaging excludes inflammatory changes

Applicable To

  • Non-inflammatory sacroiliac joint pain

Excludes

  • Inflammatory sacroiliitis (M46.1)

Clinical Validation Requirements

  • Positive Fortin test
  • Three positive provocative tests
  • Imaging excludes inflammatory changes

Code-Specific Risks

  • Incorrectly coding as inflammatory sacroiliitis without imaging

Coding Notes

  • Ensure documentation includes specific tests and imaging results to support non-inflammatory diagnosis.
View Full Code Details

Ancillary Codes

Additional codes that should be used in conjunction with the main diagnosis codes when applicable.

Low back pain

M54.5
Use to document associated low back pain.

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Sacroiliitis, not elsewhere classified

M46.1
Requires imaging confirmation of inflammation.

Sacroiliac joint dysfunction, non-inflammatory

M53.3
No imaging evidence of inflammation.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting Sacroiliac Joint Dysfunction to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M53.3.

Impact

Clinical: Leads to misdiagnosis and inappropriate treatment., Regulatory: Fails to meet documentation standards., Financial: May result in claim denials.

Mitigation Strategy

Include specific test results, Document imaging findings

Impact

Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.

Mitigation Strategy

Ensure imaging confirms inflammation before using M46.1.

Impact

Lack of specific test documentation can lead to audit failures.

Mitigation Strategy

Ensure all clinical tests and imaging are thoroughly documented.

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 Sacroiliac Joint Dysfunction, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for Sacroiliac Joint Dysfunction

Use these documentation templates to ensure complete and accurate documentation for Sacroiliac Joint Dysfunction. These templates include all required elements for proper coding and billing.

Chronic SI joint pain without trauma

Specialty: Pain Management

Required Elements

  • Positive Fortin test
  • Three positive provocative tests
  • Imaging results

Example Documentation

Patient exhibits localized tenderness over sacral sulcus with positive Fortin finger test. Imaging excludes inflammatory changes.

Examples: Poor vs. Good Documentation

Poor Documentation Example
SI joint pain present. Recommend injection.
Good Documentation Example
Tenderness isolated to right posterior superior iliac spine. Positive Fortin finger test. 80% pain reduction following dual diagnostic lidocaine/bupivacaine injections under fluoroscopy.
Explanation
The good example provides specific test results and imaging findings, supporting the diagnosis.

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