ICD-10 Coding for Hip Strain(S76.011A, S76.012A)
Complete ICD-10-CM coding and documentation guide for Hip Strain. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Hip Strain
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| S76.011A | Strain of muscle, fascia, and tendon of right hip, initial encounter | Use for initial encounters involving a right hip strain confirmed by clinical examination or imaging. |
|
| S76.012A | Strain of muscle, fascia, and tendon of left hip, initial encounter | Use for initial encounters involving a left hip strain confirmed by clinical examination or imaging. |
|
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 right hip strain
Essential facts and insights about Hip Strain
Primary ICD-10-CM Codes for hip strain
Decision Criteria
clinical Criteria
- Presence of muscle fiber disruption on imaging
documentation Criteria
- Documented laterality and encounter type
Applicable To
- Right hip muscle strain
Excludes
- Sprain of right hip (S73.1-)
Clinical Validation Requirements
- MRI or ultrasound showing muscle fiber disruption
- Physical exam findings such as tenderness and pain on resisted movement
Code-Specific Risks
- Incorrect laterality coding
- Missing 7th character for encounter type
Coding Notes
- Ensure correct laterality and encounter type are documented.
S76.012A - Strain of muscle, fascia, and tendon of left hip, initial encounter
Use for initial encounters involving a left hip strain confirmed by clinical examination or imaging.
Applicable To
- Left hip muscle strain
Excludes
- Sprain of left hip (S73.1-)
Clinical Validation Requirements
- MRI or ultrasound showing muscle fiber disruption
- Physical exam findings such as tenderness and pain on resisted movement
Coding Notes
Ensure correct 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.
Sprain of hip
S73.1-Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Hip Strain to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S76.011A.
Impact
Clinical: May lead to incorrect treatment plans., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials due to insufficient documentation.
Mitigation Strategy
Always document how the injury occurred., Use templates that prompt for mechanism of injury.
Impact
Reimbursement: May lead to claim denials or reduced reimbursement., Compliance: Non-compliance with ICD-10 specificity requirements., Data Quality: Decreases the accuracy of clinical data.
Mitigation Strategy
Always document and code the specific side (right or left) of the hip strain.
Impact
Failure to document laterality can lead to audit findings.
Mitigation Strategy
Implement mandatory fields in EMR for laterality.
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 Strain, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Hip Strain
Use these documentation templates to ensure complete and accurate documentation for Hip Strain. These templates include all required elements for proper coding and billing.
Initial evaluation of hip strain
Specialty: OrthopedicsRequired Elements
- Patient history
- Physical examination findings
- Imaging results
- Functional impact assessment
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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