ICD-10 Coding for Gluteal Hematoma(M79.81, S30.92XA)
Complete ICD-10-CM coding and documentation guide for Gluteal Hematoma. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Gluteal Hematoma
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| M79.81 | Nontraumatic hematoma of soft tissue | Use when hematoma is nontraumatic and related to factors like anticoagulant use. |
|
| S30.92XA | Contusion of unspecified buttock, initial encounter | Use when hematoma is due to trauma. |
|
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 nontraumatic gluteal hematoma
Essential facts and insights about Gluteal Hematoma
Primary ICD-10-CM Codes for gluteal hematoma
Decision Criteria
clinical Criteria
- No trauma history and anticoagulant use
Applicable To
- Nontraumatic gluteal hematoma
Excludes
- Traumatic hematoma
Clinical Validation Requirements
- No history of trauma
- Anticoagulant use
- Spontaneous onset
Code-Specific Risks
- Assuming trauma without documentation
Coding Notes
- Ensure documentation clearly states nontraumatic nature and any anticoagulant use.
S30.92XA - Contusion of unspecified buttock, initial encounter
Use when hematoma is due to trauma.
Applicable To
- Traumatic gluteal hematoma
Excludes
- Nontraumatic hematoma
Clinical Validation Requirements
- Documented trauma such as fall or accident
Coding Notes
Ensure trauma is documented and linked to the hematoma.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Gluteal Hematoma to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M79.81.
Impact
Clinical: Inaccurate clinical picture., Regulatory: Non-compliance with coding standards., Financial: Potential for denied claims.
Mitigation Strategy
Always check medication history for anticoagulants.
Impact
Reimbursement: Incorrect coding can lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Query provider to confirm if trauma is related to the hematoma.
Impact
Failure to document trauma can lead to incorrect coding.
Mitigation Strategy
Ensure trauma is clearly documented if present.
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 Gluteal Hematoma, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Gluteal Hematoma
Use these documentation templates to ensure complete and accurate documentation for Gluteal Hematoma. These templates include all required elements for proper coding and billing.
Nontraumatic gluteal hematoma in anticoagulant user
Specialty: Internal MedicineRequired Elements
- Location and size of hematoma
- Anticoagulant use
- INR levels
- Imaging results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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