How to code osteoarthritis due to hip dysplasia?

For osteoarthritis secondary to hip dysplasia, use ICD-10 code M16.2. Documentation must confirm dysplasia as the cause.

What is the ICD-10 code for bilateral hip osteoarthritis?

The ICD-10 code for bilateral primary osteoarthritis of the hip is M16.0. This code is used when both hips are affected by primary osteoarthritis.

How do you code osteoarthritis due to hip dysplasia?

For osteoarthritis secondary to hip dysplasia, use ICD-10 code M16.2. Ensure documentation confirms the dysplasia as the underlying cause.

What is the ICD-10 code for bilateral hip osteoarthritis?

The ICD-10 code for bilateral primary osteoarthritis of the hip is M16.0. This code is used when both hips are affected by primary osteoarthritis.

How do you code osteoarthritis due to hip dysplasia?

For osteoarthritis secondary to hip dysplasia, use ICD-10 code M16.2. Ensure documentation confirms the dysplasia as the underlying cause.

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ICD-10 Coding for Bilateral Hip Osteoarthritis(M16.0, M16.2)

Complete ICD-10-CM coding and documentation guide for Bilateral Hip Osteoarthritis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

Bilateral Hip OADegenerative Joint Disease of Both Hips

Related ICD-10 Code Ranges

Complete code families applicable to Bilateral Hip Osteoarthritis

M16.0-M16.9Primary Range

Osteoarthritis of hip

This range includes all codes related to osteoarthritis of the hip, including primary, secondary, and post-traumatic causes.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

Code	Description	When to Use	Key Documentation
M16.0	Bilateral primary osteoarthritis of hip	Use when bilateral hip osteoarthritis is confirmed as primary (idiopathic) through imaging and clinical evaluation.	X-ray confirmation of joint space narrowing Clinical symptoms of pain and reduced mobility
M16.2	Bilateral osteoarthritis resulting from hip dysplasia	Use when osteoarthritis is secondary to developmental dysplasia of the hip.	History of hip dysplasia Radiographic evidence of dysplasia and osteoarthritis

Clinical Decision Support

Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.

Key Information: ICD-10 code for bilateral hip osteoarthritis

Essential facts and insights about Bilateral Hip Osteoarthritis

The ICD-10 code for bilateral primary osteoarthritis of the hip is M16.0. Use this code when both hips are affected by primary osteoarthritis.

Primary ICD-10-CM Codes for bilateral hip osteoarthritis

M16.0

Bilateral primary osteoarthritis of hip

Billable Code

Decision Criteria

clinical Criteria

Bilateral hip pain and stiffness with X-ray evidence of osteoarthritis

Applicable To

Idiopathic bilateral hip osteoarthritis

Excludes

Post-traumatic osteoarthritis (M16.4)

Clinical Validation Requirements

X-ray confirmation of joint space narrowing
Clinical symptoms of pain and reduced mobility

Code-Specific Risks

Incorrectly coding as unilateral when both hips are affected
Using unspecified codes when laterality is documented

Coding Notes

Ensure documentation specifies 'bilateral' and confirms primary osteoarthritis through imaging.

View Full Code Details

Ancillary Codes

Additional codes that should be used in conjunction with the main diagnosis codes when applicable.

Presence of artificial hip joint

Z96.64-

Use when there is a history of hip replacement surgery.

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Unilateral primary osteoarthritis of hip

M16.1

Use when only one hip is affected by primary osteoarthritis.

Bilateral primary osteoarthritis of hip

M16.0

Primary osteoarthritis is idiopathic and not due to dysplasia.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting Bilateral Hip Osteoarthritis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M16.0.

Impact

Clinical: May lead to inappropriate treatment plans., Regulatory: Non-compliance with ICD-10 documentation standards., Financial: Potential for denied claims or reduced reimbursement.

Mitigation Strategy

Train staff on importance of specifying laterality, Use templates that prompt for specific details

Impact

Reimbursement: May result in lower reimbursement rates., Compliance: Non-compliance with coding guidelines., Data Quality: Reduces accuracy of clinical data.

Mitigation Strategy

Always specify laterality and use the appropriate bilateral or unilateral code.

Impact

High error rate in audits due to unspecified laterality.

Mitigation Strategy

Implement mandatory checks for laterality in documentation.

Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.

Frequently Asked Questions

Common questions about ICD-10 coding for Bilateral Hip Osteoarthritis, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for Bilateral Hip Osteoarthritis

Use these documentation templates to ensure complete and accurate documentation for Bilateral Hip Osteoarthritis. These templates include all required elements for proper coding and billing.

Orthopedic Assessment for Bilateral Hip OA

Specialty: Orthopedics

Required Elements

Patient history
Physical examination findings
Imaging results
Treatment plan

Example Documentation

Assessment: 74F with bilateral primary hip OA confirmed by X-ray. Plan: Schedule bilateral total hip arthroplasty.

Examples: Poor vs. Good Documentation

Poor Documentation Example

Hip arthritis worsening.

Good Documentation Example

Bilateral primary OA hips with 50% reduction in walking tolerance. X-ray confirms bilateral superior joint space narrowing ≥2mm.

Explanation

The good example provides specific details on laterality, severity, and imaging confirmation.

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ICD-10 Coding for Bilateral Hip Osteoarthritis(M16.0, M16.2)

Quick Navigation

Related ICD-10 Code Ranges

M16.0-M16.9Primary Range

Code Comparison: When to Use Each Code

Clinical Decision Support

Key Information: ICD-10 code for bilateral hip osteoarthritis

Primary ICD-10-CM Codes for bilateral hip osteoarthritis

Decision Criteria

clinical Criteria

Applicable To

Excludes

Clinical Validation Requirements

Code-Specific Risks

Coding Notes

M16.2 - Bilateral osteoarthritis resulting from hip dysplasia

Applicable To

Excludes

Clinical Validation Requirements

Coding Notes

Ancillary Codes

Differential Codes

Documentation & Coding Risks

Documenting 'hip arthritis' without specifying laterality

Impact

Mitigation Strategy

Using unspecified codes when laterality is documented

Impact

Mitigation Strategy

Use of unspecified codes

Impact

Mitigation Strategy

Frequently Asked Questions

Documentation Templates for Bilateral Hip Osteoarthritis

Orthopedic Assessment for Bilateral Hip OA

Required Elements

Example Documentation

Examples: Poor vs. Good Documentation

Poor Documentation Example

Good Documentation Example

Explanation

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Helpful Links

We build tools for
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