Molina Healthcare Coding Education Sacroiliitis, unspecified Documentation Examples: Assessment:LBP with XR showing Grade 2 bilat changes for sacroiliitis. HCC/ICD-9 Code: 720.2 Sacroiliitis, unspecified ICD-10 Code: M46.1 Sacroiliitis, not elsewhere classified Plan: Ifpain persists, will change meds. OR Assessment: Pt with chronic sacroiliitis, NSAIDS not helping much. HCC/ICD-9 Code: 720.2 Sacroiliitis, unspecified ICD-10 Code: M46.1 Sacroiliitis, not elsewhere classified Plan: Refer to rheumatologist to consider anti-TNF agent. Question: Can sacroiliitis be diagnosed by exam alone, demonstrating pain near or around the SI joint? Answer: No.Physical exam has not been shown to be specific for sacroiliitis.1 Diagnose by X-ray. Which must show:2 Grade 2 bilaterally or Grade 3 unilaterally X-Ray Grading for Sacroiliitis: 0. Normal 1. Suspicious changes 2. Minimal: small localized erosions or sclerosis, with no alteration of joint width 3. Unequivocal: erosions, sclerosis, widening, narrowing, or partial ankylosis 4. Severe: total ankylosis 1“Diagnosis and differential diagnosis of ankylosing spondylitis in adults” Yu, David, Aug 2013 2UpToDate: “Undifferentiated spondyloarthritis, including peripheral and non-radiographic axial spondyloarthritis, including peripheral and non-radiographic axial spondyloarthritis” Yu, David Lit review current through Aug 2013 Have Questions? Contact: Ramp@MolinaHealthcare.com The information presented herein is for informational and illustrative purposes only. It is not intended, nor is it to be used, to define a standard of care or otherwise substitute for informed medical evaluation, diagnosis and treatment which can be performed by a qualified medical professional. Molina Healthcare Inc. does not warrant or represent that the information contained herein is accurate or free from defects.