Find information on Labral Tear Right Hip diagnosis, including clinical documentation, medical coding, and healthcare resources. Learn about ICD-10 codes for right hip labral tear, right hip pain, hip arthroscopy, and labral repair surgery. Explore resources for accurate medical coding and billing for a Labral Tear Right Hip diagnosis. This page offers guidance for healthcare professionals on documenting and coding this specific condition.
Also known as
Internal derangement of knee
This includes labral tears specifically of the hip.
Dislocation and sprain of hip
May be relevant if labral tear is associated with trauma.
Pain in joint
Can be used for hip pain if a more specific diagnosis is not confirmed.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the labral tear traumatic?
Yes
Current injury?
No
Is it degenerative?
When to use each related code
Description |
---|
Labral Tear Right Hip |
Right Hip Impingement |
Right Hip Pain NOS |
Coding labral tear without specifying right hip can lead to claim rejection. Ensure documentation clarifies laterality for accurate coding (ICD-10-CM M24.471).
Failing to document the cause of the labral tear (e.g., trauma, overuse) may impact code selection. Accurate etiology ensures appropriate reimbursement and data analysis.
Discrepancies between physician notes and imaging reports regarding the labral tear can create coding and audit issues. CDI ensures documentation consistency.
Patient presents with complaints of right hip pain, consistent with a suspected labral tear. Symptoms include deep, clicking or catching sensation in the hip joint, groin pain, stiffness, limited range of motion, and occasional locking or giving way. Onset of pain is reported as gradual, possibly related to repetitive twisting or pivoting movements during sports activities six months prior. Patient reports activity-related pain exacerbated by prolonged sitting, standing, or walking. Physical examination reveals tenderness to palpation over the anterior right hip joint, positive anterior hip impingement test (FADIR), and restricted internal rotation and abduction. Differential diagnoses include osteoarthritis, femoroacetabular impingement (FAI), hip flexor strain, and iliopsoas bursitis. Preliminary diagnosis of right hip labral tear is suspected based on clinical presentation and physical exam findings. Ordered MRI of the right hip with contrast to confirm diagnosis and assess the extent of labral pathology. Conservative management will be initiated with a course of physical therapy focusing on strengthening hip stabilizers and improving range of motion. NSAIDs prescribed for pain management. Referral to orthopedic specialist will be made if symptoms do not improve with conservative treatment, or if MRI confirms significant labral tear requiring surgical intervention such as labral repair or debridement. ICD-10 code M25.551 Right hip joint derangement will be utilized pending MRI confirmation. Follow-up scheduled in four weeks to reassess progress and review imaging results.