ICD-10 Coding for Hip Dysplasia(M16.2, M16.3, Q65.89)
Complete ICD-10-CM coding and documentation guide for Hip Dysplasia. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Hip Dysplasia
M16.0-M16.9Primary Range
Osteoarthritis of hip
Covers osteoarthritis resulting from hip dysplasia, including laterality and severity.
Congenital deformities of hip
Used for congenital forms of hip dysplasia diagnosed in infancy.
Other acquired deformities of limbs
Applicable for acquired hip deformities not present at birth.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| M16.2 | Bilateral osteoarthritis resulting from hip dysplasia | Use when both hips show osteoarthritis due to dysplasia. |
|
| M16.3 | Unilateral osteoarthritis resulting from hip dysplasia | Use when one hip shows osteoarthritis due to dysplasia. |
|
| Q65.89 | Other specified congenital deformities of hip | Use for congenital hip dysplasia identified in infancy. |
|
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 hip dysplasia
Essential facts and insights about Hip Dysplasia
Primary ICD-10-CM Codes for hip dysplasia
Decision Criteria
clinical Criteria
- Bilateral hip pain with imaging showing dysplasia
Applicable To
- Bilateral hip osteoarthritis due to dysplasia
Excludes
- Primary osteoarthritis (M16.1-)
Clinical Validation Requirements
- Radiographic confirmation of bilateral acetabular dysplasia
- Documented degenerative changes
Code-Specific Risks
- Ensure bilateral involvement is documented.
Coding Notes
- Document the causal relationship between dysplasia and OA.
M16.3 - Unilateral osteoarthritis resulting from hip dysplasia
Use when one hip shows osteoarthritis due to dysplasia.
Applicable To
- Unilateral hip osteoarthritis due to dysplasia
Excludes
- Primary osteoarthritis (M16.1-)
Clinical Validation Requirements
- Radiographic confirmation of unilateral acetabular dysplasia
- Documented degenerative changes
Coding Notes
Document the causal relationship between dysplasia and OA.
Q65.89 - Other specified congenital deformities of hip
Use for congenital hip dysplasia identified in infancy.
Applicable To
- Congenital hip dysplasia not otherwise specified
Excludes
- Acquired hip deformities (M21.2-)
Clinical Validation Requirements
- Positive Ortolani/Barlow test in infants
- Ultrasound confirmation
Coding Notes
Ensure congenital nature is documented.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Labral tear of hip
M24.851Differential 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 Hip Dysplasia to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M16.2.
Impact
Clinical: May lead to incorrect treatment planning., Regulatory: Non-compliance with ICD-10 coding standards., Financial: Potential claim denials or reduced reimbursement.
Mitigation Strategy
Use documentation templates that require laterality., Educate staff on the importance of complete documentation.
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate patient records.
Mitigation Strategy
Use M21 codes for acquired conditions.
Impact
Failure to document laterality can lead to audit issues.
Mitigation Strategy
Implement mandatory laterality documentation policies.
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 Hip Dysplasia, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Hip Dysplasia
Use these documentation templates to ensure complete and accurate documentation for Hip Dysplasia. These templates include all required elements for proper coding and billing.
Adult with unilateral hip dysplasia
Specialty: OrthopedicsRequired Elements
- Patient history of hip pain
- Imaging findings
- Physical exam results
- Diagnosis and treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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