ICD-10 Guide

Pain Sacrum

ICD-10 Coding for Sacrum Pain(M54.18, M53.2X7)

PRIMARY SPECIALTYPain Management

COMPLEXITYHigh

LAST UPDATED09/15/2025

Sam Tuffun, PT, DPT

Physical Therapist | Medical Coding & Billing Contributor

Diagnosis Overview

What is Pain Sacrum?

Essential facts and insights about Sacrum Pain

Key Clinical Considerations:

Localized pain in the sacral region, often described as dull or sharp
Imaging studies may show degenerative changes or fractures
Tenderness upon palpation of the sacrum, limited range of motion in the lumbar spine

Clinical Information

Clinical Criteria & Documentation Requirements

Patient history including onset, duration, and characteristics of pain
Use of specific terms like 'sacral pain' or 'sacroiliac joint dysfunction'
Examples include detailed pain assessments and treatment plans

Coding Guidelines

Usage Guidelines & Examples

Follow guidelines for coding pain severity and duration.
Common errors include misclassifying pain as lumbar or pelvic.

Code Exclusions

Important Exclusions

Fractures of the sacrum, malignancies
M54.5 (Low back pain)

Specialty Focus

Primary Specialty

Pain Management

Specialty Applications

Adults with chronic pain conditions, post-surgical patients
Pain management clinics, orthopedic practices

Coding Complexity

High Complexity

This diagnosis requires careful attention to:

Comprehensive clinical documentation
Accurate code selection based on clinical criteria
Proper exclusion considerations
Specialty-specific coding guidelines

Documentation

Documentation Templates

Billing Information

Billing Considerations

Ensure proper documentation for billing
Verify code specificity requirements
Check for any additional codes needed
Review payer-specific guidelines

Common Issues

Insufficient clinical documentation
Incorrect code selection
Missing supporting diagnoses
Timing and frequency documentation

Frequently Asked Questions

Documentation requirements?

Include detailed patient history, physical exam findings, and treatment plans.

Billing considerations?

Ensure accurate coding to reflect the specific nature of sacral pain for proper reimbursement.

Pain Sacrum

Diagnosis Overview

Key Clinical Considerations:

Clinical Information

Clinical Criteria & Documentation Requirements

Coding Guidelines

Usage Guidelines & Examples

Code Exclusions

Important Exclusions

Related ICD-10 Codes

Related CPT Codes

Specialty Focus

Primary Specialty

Specialty Applications

Coding Complexity

Documentation

Documentation Templates

Billing Information

Billing Considerations

Common Issues

Frequently Asked Questions

Documentation requirements?

Billing considerations?

Pain Sacrum

Diagnosis Overview

Key Clinical Considerations:

Clinical Information

Clinical Criteria & Documentation Requirements

Coding Guidelines

Usage Guidelines & Examples

Code Exclusions

Important Exclusions

Related ICD-10 Codes

Related CPT Codes

Specialty Focus

Primary Specialty

Specialty Applications

Coding Complexity

Documentation

Documentation Templates

Billing Information

Billing Considerations

Common Issues

Frequently Asked Questions

Documentation requirements?

Billing considerations?