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ICD-10 Coding for Left Hip Strain(S76.012A, S76.012D, S76.012S)

Complete ICD-10-CM coding and documentation guide for Left Hip Strain. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

Left Hip Muscle StrainLeft Hip Tendon Strain

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Related ICD-10 Code Ranges

Complete code families applicable to Left Hip Strain

S76.0-S76.9Primary Range

Injury of muscle, fascia and tendon at hip and thigh level

This range includes codes for strains of muscles and tendons around the hip, including the left hip.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
S76.012AStrain of muscle, fascia and tendon of left hip, initial encounterUse for initial encounter of acute left hip strain with active treatment.
  • Pain on resisted hip flexion
  • Tenderness on palpation
  • Limited range of motion
S76.012DStrain of muscle, fascia and tendon of left hip, subsequent encounterUse for follow-up visits after initial treatment of left hip strain.
  • Documented improvement in pain and ROM
  • Ongoing rehabilitation
S76.012SStrain of muscle, fascia and tendon of left hip, sequelaUse for chronic residual effects following the healing of a left hip strain.
  • Persistent functional limitations
  • Chronic pain or weakness

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 hip strain

Essential facts and insights about Left Hip Strain

The ICD-10 code for left hip strain is S76.012A for initial encounters.

Primary ICD-10-CM Codes for left hip strain

S76.012A
Strain of muscle, fascia and tendon of left hip, initial encounter
Billable Code

Decision Criteria

clinical Criteria

  • Presence of muscle tenderness and limited ROM

documentation Criteria

  • Documented initial encounter with specific muscle involvement

Applicable To

  • Acute strain of left hip muscles

Excludes

  • Fracture of hip (S72.-)
  • Dislocation of hip (S73.-)

Clinical Validation Requirements

  • Pain on resisted hip flexion
  • Tenderness on palpation
  • Limited range of motion

Code-Specific Risks

  • Incorrect 7th character usage can lead to claim denials.

Coding Notes

  • Ensure documentation specifies laterality, encounter type, and grade of strain.
View Full Code Details

Ancillary Codes

Additional codes that should be used in conjunction with the main diagnosis codes when applicable.

Pain in left hip

M25.552
Use if pain persists after strain resolution.

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Sprain of other specified parts of left hip, initial encounter

S73.192A
Use for ligamentous injuries rather than muscle or tendon strains.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting Left Hip Strain to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S76.012A.

Impact

Clinical: May lead to inappropriate treatment plans., Regulatory: Non-compliance with documentation standards., Financial: Potential for claim denials or reduced reimbursement.

Mitigation Strategy

Always assess and document the grade of strain., Use standardized templates for documentation.

Impact

Reimbursement: May lead to claim denials or reduced payment., Compliance: Non-compliance with ICD-10 specificity requirements., Data Quality: Decreases accuracy of health records.

Mitigation Strategy

Always use specific codes for left or right hip when documented.

Impact

Using the wrong 7th character for encounter type can lead to audits.

Mitigation Strategy

Verify encounter type during documentation and coding.

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 Hip Strain, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for Left Hip Strain

Use these documentation templates to ensure complete and accurate documentation for Left Hip Strain. These templates include all required elements for proper coding and billing.

Initial encounter for left hip strain

Specialty: Orthopedics

Required Elements

  • History of present illness
  • Physical examination findings
  • Imaging results
  • Assessment and plan

Example Documentation

32yo male presents with left hip pain after a soccer match. Positive resisted hip flexion test. MRI confirms Grade 2 strain of iliopsoas. Plan: Rest, NSAIDs, and physical therapy.

Examples: Poor vs. Good Documentation

Poor Documentation Example
Left hip pain. Diagnose strain.
Good Documentation Example
Grade 2 strain of left iliopsoas muscle with ecchymosis and positive resisted hip flexion test. Mechanism: Overuse during soccer match. Initial encounter.
Explanation
The good example includes specific muscle, grade, mechanism, and encounter type.

Need help with ICD-10 coding for Left Hip Strain? Ask your questions below.

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