ICD-10 Coding for Sacral Pain(M53.3, M54.18)
Complete ICD-10-CM coding and documentation guide for Sacral Pain. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to 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 |
|---|---|---|---|
| M53.3 | Sacrococcygeal disorders, not elsewhere classified | Use for sacral pain without a more specific cause. |
|
| M54.18 | Other dorsalgia, sacral region | Use when sacral pain radiates to other areas like the buttocks. |
|
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 sacral pain
Essential facts and insights about Sacral Pain
Primary ICD-10-CM Codes for sacral pain
Decision Criteria
clinical Criteria
- Pain localized to sacral region with specific tests
Applicable To
- Localized sacral pain
Excludes
- Coccydynia (M53.2X7)
Clinical Validation Requirements
- Tenderness localized to S1-S3 region
- Negative straight leg raise
Code-Specific Risks
- Confusion with low back pain codes
Coding Notes
- Ensure documentation specifies sacral region involvement.
M54.18 - Other dorsalgia, sacral region
Use when sacral pain radiates to other areas like the buttocks.
Applicable To
- Sacral pain with radiation
Excludes
- Low back pain (M54.5)
Clinical Validation Requirements
- Central sacral pain radiating to buttocks
- Positive Fortin finger test
Coding Notes
Document radiation pattern clearly.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Chronic pain due to trauma
G89.21Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Sacral 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: Leads to inappropriate treatment plans., Regulatory: Non-compliance with coding guidelines., Financial: Potential for claim denials.
Mitigation Strategy
Educate staff on code differentiation., Use templates to guide documentation.
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: May result in non-compliance with coding standards., Data Quality: Affects accuracy of patient records.
Mitigation Strategy
Ensure documentation specifies sacral region involvement.
Impact
Lack of specificity in documentation can lead to audit findings.
Mitigation Strategy
Use detailed templates and training to ensure specificity.
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 Sacral Pain, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Sacral Pain
Use these documentation templates to ensure complete and accurate documentation for Sacral Pain. These templates include all required elements for proper coding and billing.
Physical Therapy Initial Evaluation
Specialty: Physical TherapyRequired Elements
- Subjective pain description
- Objective findings
- Special tests
- Impression
- Plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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