M46.38

Billable

Infection of intervertebral disc (pyogenic), sacral and sacrococcygeal region

HCC Category Mapping

V28HCC 92 — Bone/Joint/Muscle Infections/Necrosis

0.209

V24HCC 39 — Bone/Joint/Muscle Infections/Necrosis

0.482

ESRDHCC 39 — Bone/Joint/Muscle Infections/Necrosis

0.000

What This Code Means

A bacterial infection of the intervertebral disc in the sacral and sacrococcygeal region at the base of the spine.

Coding Tips

•This is a less common site for discitis; ensure documentation supports sacral/sacrococcygeal location
•May be associated with pelvic infections or procedures

Clinical Significance

Sacral and sacrococcygeal discitis is relatively rare but challenging to treat due to limited blood supply and unique anatomy of this region. The condition may be associated with genitourinary or gastrointestinal sources of infection requiring comprehensive evaluation.

Documentation Requirements

✓Specific sacral and sacrococcygeal region involvement
✓Bacterial culture results and source identification
✓Imaging of sacral disc spaces and coccygeal articulations
✓Assessment for genitourinary or GI tract sources
✓Pelvic floor function evaluation
✓Bowel and bladder function assessment
✓Pain severity and functional impact
✓Response to targeted antibiotic therapy

Commonly Confused Codes

M46.37 — Lumbosacral region when infection at L5-S1 level M46.58 — Other infective spondylopathies same region when non-bacterial M53.3 — Sacrococcygeal disorders when non-infectious N34.1 — Nonspecific urethritis when GU symptoms predominate