Find information on Osteoarthritis of Left Hip diagnosis including ICD-10-CM code M16.12, clinical documentation requirements, medical coding guidelines, and healthcare resources. Learn about left hip osteoarthritis symptoms, treatment options, and best practices for accurate medical record keeping. This resource provides comprehensive information for physicians, coders, and healthcare professionals regarding Osteoarthritis Left Hip.
Also known as
Coxarthrosis
Osteoarthritis of hip
Arthroses
Joint diseases mainly involving cartilage degeneration
Musculoskeletal diseases
Diseases of the musculoskeletal system and connective tissue
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the osteoarthritis primary (idiopathic)?
Yes
Unilateral or bilateral involvement?
No
Is it post-traumatic?
When to use each related code
| Description |
|---|
| Osteoarthritis Left Hip |
| Left Hip Pain |
| Left Hip Internal Derangement |
Coding left hip OA as right or unspecified hip creates documentation and billing errors impacting reimbursement.
Failing to capture primary vs. secondary OA, post-traumatic vs. age-related, or hip joint vs. other location impacts data accuracy.
Lack of documentation for associated pain, stiffness, or functional limitations with left hip OA leads to undercoding and HCC implications.
Patient presents with complaints of left hip pain, stiffness, and limited range of motion, consistent with osteoarthritis of the left hip. Symptoms include morning stiffness lasting less than 30 minutes, pain exacerbated by weight-bearing activities such as walking and standing, and crepitus with movement. The patient reports experiencing left hip joint pain for the past six months, gradually worsening in severity. Physical examination reveals tenderness to palpation over the left hip joint, reduced internal and external rotation, and pain with passive range of motion. Radiographic imaging of the left hip demonstrates joint space narrowing, osteophyte formation, and subchondral sclerosis, confirming the diagnosis of osteoarthritis. Assessment includes left hip osteoarthritis, ICD-10 code M16.11. Differential diagnoses considered included avascular necrosis, trochanteric bursitis, and referred pain from the lumbar spine. The patient was educated on conservative management options including weight loss, regular low-impact exercise such as swimming and cycling, physical therapy to improve range of motion and muscle strength, and over-the-counter pain relievers such as acetaminophen or NSAIDs. A prescription for ibuprofen was provided for pain management. The patient was advised to follow up in four weeks to assess symptom improvement and discuss further treatment options if necessary, such as viscosupplementation injections or referral to orthopedics for surgical intervention. The patient verbalized understanding of the diagnosis, treatment plan, and potential risks and benefits.