ICD-10 Coding for Left Buttock Pain(M54.32, M79.652, M25.552)
Complete ICD-10-CM coding and documentation guide for Left Buttock Pain. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Left Buttock Pain
M54.3-M54.5Primary Range
Dorsalgia and Sciatica
Includes codes for sciatica and dorsalgia, relevant for nerve-related buttock pain.
Other Disorders of Arteries and Arterioles
Relevant for vascular causes of buttock pain, such as claudication.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| M54.32 | Sciatica, left side | Use when pain radiates down the leg with confirmed nerve involvement. |
|
| M79.652 | Pain in left thigh | Use when pain is localized to the buttock without nerve involvement. |
|
| M25.552 | Pain in left hip | Use when pain is related to hip joint pathology. |
|
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 left buttock pain
Essential facts and insights about Left Buttock Pain
Primary ICD-10-CM Codes for left buttock pain
Decision Criteria
clinical Criteria
- Presence of radicular symptoms
documentation Criteria
- Detailed description of pain radiation and neurological findings
Applicable To
- Left-sided sciatica with nerve involvement
Excludes
- Non-radiating buttock pain
Clinical Validation Requirements
- Positive straight leg raise test
- MRI showing nerve root compression
Code-Specific Risks
- Misclassification if no neurological symptoms are present
Coding Notes
- Ensure documentation of neurological symptoms for accurate coding.
M79.652 - Pain in left thigh
Use when pain is localized to the buttock without nerve involvement.
Applicable To
- Non-specific pain in the left thigh region
Excludes
- Sciatica
Clinical Validation Requirements
- Localized pain without radiation
- Negative neurological tests
Coding Notes
Ensure clear documentation of pain location and characteristics.
M25.552 - Pain in left hip
Use when pain is related to hip joint pathology.
Applicable To
- Pain associated with hip joint movement
Excludes
- Non-joint related buttock pain
Clinical Validation Requirements
- Pain worsens with hip movement
- Imaging showing joint pathology
Coding Notes
Document joint involvement clearly.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Intervertebral disc disorders with radiculopathy, lumbar region
M51.16Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Left Buttock Pain to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M54.32.
Impact
Clinical: May lead to inappropriate treatment., Regulatory: Increases risk of audit., Financial: Potential for denied claims.
Mitigation Strategy
Use detailed anatomical terms., Include neurological findings if present.
Impact
Reimbursement: May lead to incorrect DRG assignment., Compliance: Potential audit risk for incorrect coding., Data Quality: Impacts data accuracy for clinical research.
Mitigation Strategy
Use M54.32 if sciatica is confirmed or M79.652 for localized pain.
Impact
Coding sciatica without documented nerve involvement.
Mitigation Strategy
Ensure neurological findings are documented.
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 Left Buttock Pain, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Left Buttock Pain
Use these documentation templates to ensure complete and accurate documentation for Left Buttock Pain. These templates include all required elements for proper coding and billing.
Left buttock pain with nerve involvement
Specialty: OrthopedicsRequired Elements
- Pain description
- Radiation pattern
- Neurological findings
- Imaging results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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