Traumatic spondylopathy confined to the sacral and sacrococcygeal vertebral segments — structural spinal damage in the sacrum or coccyx resulting from trauma rather than degenerative or inflammatory disease.
Verified May 8, 2026 · 5 sources ↓
- Status
- Billable
- Chapter
- 13
- Related CPT
- 10
- Region
- Spine
Documentation tips
What should appear in the chart to support M48.38.
Source · Editorial brief grounded in 5 cited references ↓
- Specify the region as sacral, sacrococcygeal, or both — avoid generic 'low back' or 'pelvic' language that will not support this code at audit.
- Document the precipitating traumatic event (date, mechanism, and prior fracture or injury diagnosis) to establish why a chronic spondylopathy code is appropriate rather than an acute S-code.
- Record current structural findings — imaging evidence of sacral deformity, altered alignment, or bone remodeling — to differentiate traumatic from degenerative or other pathological origins.
- Note the phase of care explicitly: if the patient is past the acute fracture window and being treated for residual instability or chronic pain, state that in the assessment to justify using an M-code over an S-code.
- If neurological involvement is present (e.g., sacral nerve root compromise), add a secondary code for the associated radiculopathy or neurogenic deficit to fully capture clinical complexity.
Related CPT procedures
Procedure codes commonly billed with M48.38. Linking the right diagnosis to the right procedure is what establishes medical necessity.
Source · CMS LCDs · AAOS specialty guidance · claims-pattern analysis
Common coding pitfalls
The recurring mistakes coders make with M48.38 and adjacent codes.
Source · Editorial brief grounded in CDC ICD-10-CM tabular guidance, AAOS coding references, and cited references ↓
- Assigning M48.38 for an acute sacral fracture — active fractures require an S-series injury code with the correct 7th character (A/D/S), not an M-code.
- Using M48.38 when the pathology spans the lumbosacral junction — that presentation maps to M48.37, not M48.38; review imaging to confirm which region is primarily affected.
- Conflating traumatic spondylopathy with osteoporotic or pathological collapse — M48.38 requires a traumatic etiology; osteoporosis-related collapse codes to M80 series.
- Omitting the trauma history in documentation, leaving no clinical basis to distinguish M48.38 from a degenerative spondylopathy (M47 series) — payers may deny or downcode without a documented injury trigger.
- Submitting M48.3 (parent, non-billable) instead of the fully specified M48.38 — M48.3 is not a valid billing code; M48.38 is the billable child code for this region.
Clinical context
Source · Editorial summary grounded in 5 cited references ↓
M48.38 applies when trauma has produced pathological changes in the sacral or sacrococcygeal vertebrae — such as altered vertebral architecture, ligamentous disruption, or chronic instability — that do not meet the specificity threshold of a discrete fracture code. Use it for ongoing management of sacral/coccygeal spinal injury sequelae when the acute fracture phase has resolved and no active fracture code is appropriate. It belongs to parent category M48.3 (Traumatic spondylopathy), which covers post-traumatic vertebral pathology across all spinal regions.
Do not use M48.38 for an acute sacral fracture. Active fractures are captured under injury codes (S-series) with the appropriate 7th-character extension (A for initial encounter, D for subsequent, S for sequela). M48.38 is appropriate once the acute injury phase has passed and the treating provider documents residual sacral or sacrococcygeal structural compromise attributed to prior trauma. It also appears on CMS's list of ICD-10-CM codes that support medical necessity for chiropractic manipulative treatment (CMT) under the AT-modifier framework.
The sacrococcygeal distinction matters here: if the injury or pathology spans the lumbosacral junction, consider M48.37 (traumatic spondylopathy, lumbosacral region) instead. When both regions are affected, code each level if documentation supports it and payer policy permits multiple spinal codes.
Sibling codes
Other billable codes under M48.3 (laterality / anatomic variants).
Frequently asked questions
Source · Generated from the editorial pipeline, verified against 5 cited references ↓
01Is M48.38 appropriate for a fresh sacral fracture seen in the ED?
02What is the difference between M48.38 and M48.37?
03Can M48.38 be used to support medical necessity for chiropractic services?
04Does M48.38 require a 7th character?
05How do I code concurrent neurological deficits caused by sacral traumatic spondylopathy?
06What imaging documentation best supports M48.38?
Sources & references
Editorial content was developed using the following public sources. Last verified May 8, 2026.
- 01CDC ICD-10-CM Tabular List 2026 (FY2026, effective Oct 1, 2025)
- 02icd10data.comhttps://www.icd10data.com/ICD10CM/Codes/M00-M99/M45-M49/M48-/M48.38
- 03aapc.comhttps://www.aapc.com/codes/icd-10-codes/M48.38
- 04cms.govhttps://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=56273
- 05cdek.pharmacy.purdue.eduhttp://cdek.pharmacy.purdue.edu/icd10/M48.3/
Mira AI Scribe
The Mira AI Scribe captures the mechanism and date of the original sacral or coccygeal injury, current imaging findings (CT or MRI evidence of sacral structural change, deformity, or remodeling), and the provider's explicit statement that acute fracture has resolved with residual traumatic spondylopathy. This prevents downcoding to an unspecified spondylopathy, rejection for missing trauma history, or mismatch with an acute S-code when the injury is no longer in the active phase.
See how Mira captures M48.38 documentation