ICD-10 Coding for Right Hip Strain(S76.011A)
Complete ICD-10-CM coding and documentation guide for Right Hip Strain. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Right Hip Strain
S76.0-S76.9Primary Range
Injury of muscle, fascia and tendon at hip and thigh level
This range includes codes for various injuries to the muscles, fascia, and tendons of the hip and thigh, including strains.
Key Information: ICD-10 code for right hip strain
Essential facts and insights about Right Hip Strain
Primary ICD-10-CM Code for right hip strain
Decision Criteria
clinical Criteria
- Presence of tenderness and positive physical tests for hip strain
documentation Criteria
- Detailed description of the mechanism of injury and clinical findings
Applicable To
- Right hip muscle strain
- Right hip tendon strain
Clinical Validation Requirements
- Tenderness to palpation of right iliopsoas/greater trochanter
- Positive resisted hip flexion test with weakness
- MRI showing muscle fiber disruption
Code-Specific Risks
- Omitting the 7th character for encounter type
- Using unspecified codes when laterality is known
Coding Notes
- Ensure documentation includes the mechanism of injury and specific tests performed.
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 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: Inaccurate tracking of patient encounters, Regulatory: Non-compliance with ICD-10 coding standards, Financial: Potential claim denials or delays
Mitigation Strategy
Ensure the correct 7th character is added for each encounter type, Review coding guidelines for encounter types
Impact
Reimbursement: Claims may be denied or delayed due to lack of specificity., Compliance: Non-compliance with coding guidelines for specificity., Data Quality: Decreased accuracy in clinical data reporting.
Mitigation Strategy
Always use S76.011A for right hip strain when laterality is documented.
Impact
Risk of using unspecified codes when specific codes are available.
Mitigation Strategy
Regular training on ICD-10 specificity requirements and audits of coding practices.
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 Hip Strain, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Right Hip Strain
Use these documentation templates to ensure complete and accurate documentation for Right Hip Strain. These templates include all required elements for proper coding and billing.
Initial Evaluation of Right Hip Strain
Specialty: OrthopedicsRequired Elements
- History of present illness
- Physical examination findings
- Imaging results
- Assessment and plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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