Segmental and somatic dysfunction of sacral region

This code describes impaired biomechanical function of the sacrum, characterized by altered joint motion, muscle spasm, tissue texture changes, and/or tenderness. It indicates a functional disturbance rather than a structural lesion or inflammatory process. This dysfunction can contribute to lower back pain, pelvic pain, and radiating symptoms.

Apply this code when documentation specifies sacral somatic dysfunction identified through physical examination findings such as restricted range of motion, asymmetry, tissue texture abnormalities, or tenderness in the sacral region. It is commonly used for patients presenting with mechanical low back pain or sacroiliac joint dysfunction. Documentation should clearly indicate the region of dysfunction.

• Do not use this code for structural sacral abnormalities (e.g., fractures, congenital anomalies); instead, refer to codes in Chapter 13 (Diseases of the musculoskeletal system and connective tissue).
• This code is often used in conjunction with codes for the presenting symptoms, such as low back pain (M54.5-).
• Ensure the documentation specifies "sacral region" to differentiate from other spinal regions of somatic dysfunction.