Complete ICD-10-CM coding and documentation guide for icd-10 coding for gluteus medius tear includes clinical validation requirements, medical necessity guidelines, and coding policies.
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Essential facts and insights about ICD-10 Coding for Gluteus Medius Tear
Use ICD-10 code S76.311D for strain of muscle, fascia and tendon of right hip, subsequent encounter, ensuring proper documentation in clinical notes.
Additional codes that may be used with this diagnosis
Arthrocentesis, aspiration and/or injection into a joint
Use for diagnostic or therapeutic joint injections.
Pain in unspecified hip
Document associated hip pain when present.
The ICD-10 code for a gluteus medius tear is S76.311D for a right hip strain, subsequent encounter, and M66.358 for a spontaneous rupture of the hip tendon.
A gluteus medius tear is diagnosed through clinical examination and confirmed with imaging, such as MRI, which shows tendon discontinuity and T2 hyperintensity.