ICD-10 Coding for Gluteus Medius Tear(S76.311D, M66.358)
Complete ICD-10-CM coding and documentation guide for Gluteus Medius Tear. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Gluteus Medius Tear
S76.3Primary Range
Injury of muscle, fascia and tendon at hip and thigh level
This range includes codes for injuries to the hip muscles, including the gluteus medius.
Spontaneous rupture of other tendons
This range is used for atraumatic tears of tendons, including degenerative tears of the gluteus medius.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| S76.311D | Strain of muscle, fascia and tendon of right hip, subsequent encounter | Use for subsequent encounters of right hip strain, particularly degenerative tears. |
|
| M66.358 | Spontaneous rupture of other tendons, hip | Use for atraumatic, degenerative tears of the hip tendons. |
|
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 gluteus medius tear
Essential facts and insights about Gluteus Medius Tear
Primary ICD-10-CM Codes for gluteus medius tear
Decision Criteria
clinical Criteria
- MRI shows degenerative changes without acute trauma.
Applicable To
- Degenerative tear of right gluteus medius
Excludes
- Laceration of muscle, fascia and tendon of hip (S76.21)
Clinical Validation Requirements
- MRI-confirmed tear
- Positive Trendelenburg sign
Code-Specific Risks
- Confusion with laceration codes
Coding Notes
- Ensure documentation specifies the tear as degenerative and not traumatic.
M66.358 - Spontaneous rupture of other tendons, hip
Use for atraumatic, degenerative tears of the hip tendons.
Applicable To
- Atraumatic tear of gluteus medius
Excludes
- Traumatic rupture of tendon (S76.3)
Clinical Validation Requirements
- MRI shows tendon degeneration
- No history of acute trauma
Coding Notes
Document the absence of trauma to justify the use of M66.358.
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 Gluteus Medius Tear to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S76.311D.
Impact
Clinical: Leads to incomplete clinical records., Regulatory: May trigger audits for incomplete documentation., Financial: Can result in claim denials or delays.
Mitigation Strategy
Always document right or left side in clinical notes., Verify laterality in imaging reports.
Impact
Reimbursement: Incorrect coding can lead to denied claims., Compliance: Misclassification may result in compliance audits., Data Quality: Affects accuracy of medical records and data reporting.
Mitigation Strategy
Ensure documentation specifies the tear as a strain or degenerative tear, not a laceration.
Impact
Misclassification of degenerative tears as traumatic.
Mitigation Strategy
Ensure documentation clearly distinguishes between traumatic and degenerative tears.
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 Gluteus Medius Tear, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Gluteus Medius Tear
Use these documentation templates to ensure complete and accurate documentation for Gluteus Medius Tear. These templates include all required elements for proper coding and billing.
Chronic Degenerative Tear
Specialty: OrthopedicsRequired Elements
- Patient history
- Physical exam findings
- Imaging results
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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