Find information on hip osteoarthritis diagnosis, including clinical documentation, medical coding (ICD-10-CM M16), and healthcare resources. Learn about symptoms, treatment, and management of hip OA for accurate medical records and optimal patient care. Explore resources for healthcare professionals related to hip osteoarthritis diagnosis, coding best practices, and clinical guidelines.
Also known as
Coxarthrosis
Osteoarthritis of the hip.
Polyarthrosis
Osteoarthritis involving multiple joints, potentially including the hip.
Other arthrosis
Unspecified arthrosis that could encompass hip osteoarthritis in some cases.
Arthritides
Broad category including various joint disorders such as hip osteoarthritis.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the hip osteoarthritis primary (idiopathic)?
Yes
Code M16.9 Unilateral primary osteoarthritis, unspecified hip
No
Is it post-traumatic?
When to use each related code
| Description |
|---|
| Hip Osteoarthritis |
| Femoroacetabular Impingement |
| Avascular Necrosis of Femoral Head |
Missing or incorrect laterality (right, left, bilateral) for hip osteoarthritis impacts reimbursement and data accuracy. Important for medical coding and CDI.
Coding osteoarthritis unspecified (M19.90) when a more specific diagnosis like primary (M16) or secondary (M19.0-M19.8) is documented. Healthcare compliance risk.
Failing to capture comorbidities like obesity or past trauma impacting hip osteoarthritis severity. Affects DRG assignment and quality reporting for CDI.
Patient presents with complaints consistent with hip osteoarthritis. Symptoms include gradual onset of deep, aching hip pain, stiffness, and limited range of motion. Pain is exacerbated by weight-bearing activities and may radiate to the groin, buttock, or thigh. Morning stiffness is common, typically resolving within 30 minutes. Patient reports functional limitations such as difficulty with walking, climbing stairs, and putting on shoes and socks. Physical examination reveals decreased hip internal rotation and abduction, tenderness to palpation over the anterior hip joint, and possible crepitus with movement. Radiographic imaging of the affected hip demonstrates joint space narrowing, osteophyte formation, and subchondral sclerosis, confirming the diagnosis of hip osteoarthritis. Differential diagnosis includes trochanteric bursitis, avascular necrosis, and lumbar radiculopathy. Treatment plan includes conservative management with NSAIDs for pain relief, physical therapy focusing on range of motion and strengthening exercises, and weight management. Patient education provided regarding activity modification and assistive devices. Referral to orthopedics considered for further evaluation and management if conservative measures fail. Follow-up scheduled to assess response to treatment and discuss potential intra-articular injections or surgical intervention if indicated. ICD-10 code M16. CPT codes for evaluation and management, physical therapy, and potential injections or surgery will be documented separately as performed.