ICD-10 Coding for Gluteus Medius Strain(S76.311A, S76.312A)
Complete ICD-10-CM coding and documentation guide for Gluteus Medius Strain. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Gluteus Medius Strain
S76.3Primary Range
Injury of muscle, fascia and tendon at hip and thigh level
This range includes codes for strains of the gluteal muscles, including the gluteus medius.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| S76.311A | Strain of muscle, fascia and tendon of right hip, initial encounter | Use for initial encounter of right gluteus medius strain with documented traumatic mechanism. |
|
| S76.312A | Strain of muscle, fascia and tendon of left hip, initial encounter | Use for initial encounter of left gluteus medius strain with documented traumatic mechanism. |
|
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 gluteus medius strain
Essential facts and insights about Gluteus Medius Strain
Primary ICD-10-CM Codes for gluteus medius strain
Decision Criteria
clinical Criteria
- Presence of traumatic mechanism and localized tenderness
Applicable To
- Right gluteus medius strain
Excludes
- Tear of muscle (S76.321A)
Clinical Validation Requirements
- Tenderness over right greater trochanter
- Positive Trendelenburg sign
- MRI shows edema without tear
Code-Specific Risks
- Confusing with tear codes
- Incorrect laterality documentation
Coding Notes
- Ensure laterality and encounter type are documented.
S76.312A - Strain of muscle, fascia and tendon of left hip, initial encounter
Use for initial encounter of left gluteus medius strain with documented traumatic mechanism.
Applicable To
- Left gluteus medius strain
Excludes
- Tear of muscle (S76.322A)
Clinical Validation Requirements
- Tenderness over left greater trochanter
- Positive Trendelenburg sign
- MRI shows edema without tear
Coding Notes
Ensure laterality and encounter type are documented.
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 Gluteus Medius Strain to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S76.311A.
Impact
Clinical: Ambiguity in treatment planning., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials.
Mitigation Strategy
Always document laterality in clinical notes.
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with ICD-10 guidelines., Data Quality: Inaccurate clinical data recording.
Mitigation Strategy
Verify clinical documentation for presence of tear vs. strain.
Impact
Failure to document laterality can lead to audit issues.
Mitigation Strategy
Implement checklist for documentation completeness.
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 Gluteus Medius Strain, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Gluteus Medius Strain
Use these documentation templates to ensure complete and accurate documentation for Gluteus Medius Strain. These templates include all required elements for proper coding and billing.
Initial evaluation of gluteus medius strain
Specialty: OrthopedicsRequired Elements
- Mechanism of injury
- Laterality
- Physical exam findings
- Imaging results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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