ICD-10 Coding for Right Buttock Pain(M54.31, G57.01, S39.012D)
Complete ICD-10-CM coding and documentation guide for Right Buttock Pain. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Right Buttock Pain
M54.3-M54.5Primary Range
Dorsalgia, including sciatica and low back pain
Includes codes for sciatica and low back pain, which are common causes of buttock pain.
Mononeuropathies of lower limb
Includes piriformis syndrome, which can cause buttock pain due to sciatic nerve compression.
Injuries to the abdomen, lower back, lumbar spine, pelvis, and external genitals
Includes codes for strains and injuries that may cause acute buttock pain.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| M54.31 | Sciatica, right side | Use when sciatica is confirmed by clinical tests and imaging. |
|
| G57.01 | Lesion of sciatic nerve, right lower limb | Use when piriformis syndrome is diagnosed with specific tests. |
|
| S39.012D | Strain of muscle, fascia and tendon of lower back, subsequent encounter | Use for acute injuries with clear traumatic origin. |
|
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 buttock pain
Essential facts and insights about Right Buttock Pain
Primary ICD-10-CM Codes for right buttock pain
Decision Criteria
clinical Criteria
- Presence of dermatomal pain map and positive SLR test.
Applicable To
- Right-sided sciatica
Excludes
- Piriformis syndrome (G57.01)
Clinical Validation Requirements
- Radiation below knee
- Positive straight leg raise (SLR) test
Code-Specific Risks
- Misdiagnosis if imaging does not support nerve root compression.
Coding Notes
- Ensure laterality is documented to avoid unspecified codes.
G57.01 - Lesion of sciatic nerve, right lower limb
Use when piriformis syndrome is diagnosed with specific tests.
Applicable To
- Right piriformis syndrome
Excludes
- Sciatica (M54.31)
Clinical Validation Requirements
- Positive FAIR test
- EMG showing sciatic neuropathy
Coding Notes
Document specific tests like the FAIR test to support diagnosis.
S39.012D - Strain of muscle, fascia and tendon of lower back, subsequent encounter
Use for acute injuries with clear traumatic origin.
Applicable To
- Right gluteal strain
Excludes
- Chronic pain without acute injury
Clinical Validation Requirements
- Acute trauma history
- Localized swelling or ecchymosis
Coding Notes
Ensure documentation of trauma and physical findings.
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 Right Buttock Pain to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M54.31.
Impact
Clinical: Leads to inaccurate patient records., Regulatory: Non-compliance with coding guidelines., Financial: Potential for denied claims.
Mitigation Strategy
Always document the side of the body affected.
Impact
Reimbursement: Incorrect coding can lead to denied claims., Compliance: Non-compliance with coding standards., Data Quality: Inaccurate clinical data and patient records.
Mitigation Strategy
Use specific clinical tests like SLR for sciatica and FAIR test for piriformis syndrome.
Impact
Failure to document laterality can lead to audit issues.
Mitigation Strategy
Implement a checklist to ensure laterality is 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 Right Buttock Pain, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Right Buttock Pain
Use these documentation templates to ensure complete and accurate documentation for Right Buttock Pain. These templates include all required elements for proper coding and billing.
Orthopedic evaluation for right buttock pain
Specialty: OrthopedicsRequired Elements
- Pain location and radiation
- Aggravating and relieving factors
- Neurological examination findings
- Imaging results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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