ICD Code M46.1

ICD code M46.1 is a classification used to identify sacroiliitis, which is an inflammation of one or both of the sacroiliac joints, located where the lower spine and pelvis connect. This code is used when the condition is not specified under any other classification, allowing healthcare providers to document and bill for this specific diagnosis accurately.

1. Chronic Lower Back Pain: Persistent pain localized in the lower back region, particularly around the sacroiliac joints, that lasts for more than three months.

2. Pelvic Pain: Discomfort or pain in the pelvic area that may radiate to the buttocks or thighs, often exacerbated by prolonged sitting or standing.

3. Stiffness in the Lower Back: A noticeable reduction in the range of motion in the lower back, especially after periods of inactivity or in the morning.

4. Tenderness Over Sacroiliac Joints: Palpable tenderness or pain when pressure is applied directly over the sacroiliac joints during a physical examination.

5. Inflammatory Markers: Elevated levels of inflammatory markers such as C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) in blood tests, indicating an inflammatory process.

6. Positive Imaging Findings: Evidence of inflammation or structural changes in the sacroiliac joints observed through imaging studies such as X-rays, MRI, or CT scans.

7. Exclusion of Other Conditions: Ruling out other potential causes of lower back pain and pelvic discomfort, such as lumbar disc herniation, hip joint disorders, or other forms of arthritis.

8. Response to Anti-inflammatory Treatment: Improvement of symptoms with the use of non-steroidal anti-inflammatory drugs (NSAIDs) or other anti-inflammatory treatments, supporting an inflammatory etiology.

9. Family History: A family history of similar symptoms or related inflammatory conditions, which may suggest a genetic predisposition.

10. Age of Onset: Typically, symptoms begin in young adulthood, often before the age of 40, and may progressively worsen over time.

For the ICD code M46.1 (Sacroiliitis, not elsewhere classified), the relevant CPT codes that may be applicable for treatment include:

1. 20610 - Arthrocentesis, aspiration, and/or injection into a major joint or bursa (e.g., sacroiliac joint), without ultrasound guidance.

2. 27096 - Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT).

3. 20552 - Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s).

4. 20553 - Injection(s); single or multiple trigger point(s), 3 or more muscles.

5. 64451 - Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level.

These CPT codes are commonly used in the treatment of conditions associated with sacroiliitis, such as pain management and joint injections. It is important for healthcare providers to select the appropriate CPT code based on the specific treatment and procedures performed. Always ensure that the chosen CPT code aligns with the services rendered and is supported by proper documentation.

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