2025 ICD-10-CM code M53.3
(Active) Effective Date: N/A Diseases of the musculoskeletal system and connective tissue - Other dorsopathies XIII Feed
Sacrococcygeal disorders, not elsewhere classified. This includes conditions affecting the base of the spine and tailbone, such as coccygodynia (coccyx pain).
Medical necessity is established by documenting the patient's pain, its impact on their activities of daily living, and the failure of conservative treatments to provide relief. For surgical intervention, the documentation should clearly justify the need for the procedure.
Clinicians diagnose sacrococcygeal disorders through patient history, physical exam, and imaging (X-rays, CT, MRI, discography). Treatment includes pain relief medication (analgesics, corticosteroids, NSAIDs), injections, physical therapy, postural training, special cushions, and, in severe cases, surgery (coccygectomy).
In simple words: This code represents disorders of the tailbone, often causing pain that worsens when sitting. This pain can be caused by falls, childbirth, obesity, tumors, arthritis, or infections.
Sacrococcygeal disorders encompass various conditions affecting the sacrum and coccyx (tailbone). Coccygodynia, commonly known as tailbone pain, is a frequent example. Other disorders within this category include those not specifically classified elsewhere in the ICD-10-CM.
Example 1: A patient presents with tailbone pain after falling on their buttocks. Imaging rules out fractures, and the diagnosis is coccygodynia (M53.3)., A patient experiences persistent tailbone pain after childbirth. Examination and imaging confirm a diagnosis of a sacrococcygeal disorder (M53.3)., A patient with a history of obesity reports chronic tailbone pain. After conservative treatments fail, a coccygectomy is performed, still coded as M53.3.
Documentation should include the patient's history, physical examination findings, imaging results, and details of treatments provided. Specific symptoms, the onset and duration of pain, and any contributing factors should be noted.
- Specialties:Orthopedics, Pain Management, Physical Medicine and Rehabilitation, Family Medicine
- Place of Service:Office, Inpatient Hospital, Outpatient Hospital, Emergency Room - Hospital,Ambulatory Surgical Center,Physical Therapy Clinic