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S70.311A
ICD-10-CM
Right Thigh Hematoma

Find information on right thigh hematoma diagnosis, including clinical documentation, medical coding, ICD-10 codes, and healthcare guidelines. Learn about symptoms, treatment, and best practices for documenting a right thigh hematoma in medical records. This resource provides valuable insights for physicians, nurses, and other healthcare professionals seeking accurate and comprehensive information on right thigh hematoma. Explore relevant medical terminology, differential diagnosis considerations, and coding guidelines for optimal patient care and accurate billing.

Also known as

Thigh Contusion
Thigh Bruise

Diagnosis Snapshot

Key Facts
  • Definition : A collection of blood outside of blood vessels within the right thigh muscle.
  • Clinical Signs : Pain, swelling, bruising, and limited range of motion in the affected thigh.
  • Common Settings : Trauma, muscle strain, bleeding disorders, anticoagulant therapy.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC S70.311A Coding
S70-S79

Injuries to the hip and thigh

Covers injuries like contusions and hematomas of the thigh region.

M79.89

Other specified soft tissue disorders

Includes other specified soft tissue disorders, not elsewhere classified.

S00-T88

Injury, poisoning and certain other consequences of external causes

Broad category encompassing various injuries, including potential hematoma causes.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is the right thigh hematoma traumatic?

  • Yes

    Is there a current injury?

  • No

    Is it related to anticoagulant therapy?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Right thigh bruise
Right thigh hematoma
Right thigh contusion

Documentation Best Practices

Documentation Checklist
  • Document hematoma size, location, and characteristics.
  • Note mechanism of injury or causative factors.
  • Record pain level and associated symptoms.
  • Document any functional limitations or impact on mobility.
  • Include relevant medical history, medications, allergies.

Coding and Audit Risks

Common Risks
  • Unspecified Trauma

    Coding hematoma without specifying the traumatic cause (e.g., fall, contusion) leads to unspecified codes and claim denials. CDI crucial.

  • Laterality and Specificity

    Lack of right thigh laterality or anatomical specificity (e.g., anterior, posterior) impacts coding accuracy and reimbursement. CDI query needed.

  • Documentation Deficiency

    Missing documentation linking the right thigh hematoma to an underlying condition or injury creates coding and compliance issues. CDI review essential.

Mitigation Tips

Best Practices
  • Accurate ICD-10 coding (e.g., S70.0-, S70.1-) for right thigh hematoma.
  • Detailed HPI documentation: size, onset, mechanism of injury, symptoms.
  • Monitor for compartment syndrome: document neurovascular assessments.
  • Consider imaging (ultrasound/MRI): document need & link to diagnosis.
  • Timely follow-up: document evolution, treatment response, and patient education.

Clinical Decision Support

Checklist
  • Verify trauma history, physical exam findings.
  • Review imaging (e.g., ultrasound, MRI) to confirm hematoma.
  • Assess size, location, and characteristics of hematoma.
  • Check coagulation studies (PT, PTT, INR) if indicated.

Reimbursement and Quality Metrics

Impact Summary
  • Right Thigh Hematoma reimbursement impacts ICD-10 coding accuracy, affecting DRG assignment and hospital payments.
  • Hematoma diagnosis coding quality metrics influence hospital value-based purchasing and pay-for-performance programs.
  • Accurate thigh hematoma coding impacts physician profiling, hospital quality reporting, and public healthcare data transparency.
  • Coding compliance for hematoma reduces claim denials, improves revenue cycle management, and optimizes hospital financial performance.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes. Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • Code M79.81 for right thigh hematoma
  • Document size, location, and cause
  • Query physician if cause is unclear
  • Consider 729.5 for chronic hematoma
  • Link to trauma if applicable

Documentation Templates

Patient presents with complaints of right thigh pain, swelling, and bruising consistent with a right thigh hematoma.  Onset of symptoms reported as [onset timeframe, e.g., two days ago] following [mechanism of injury/cause, e.g., a fall, direct blow to the thigh, spontaneous onset].  Patient denies any fever, chills, or open wounds.  Physical examination reveals ecchymosis and palpable tenderness localized to the [specific location on right thigh, e.g., anterior, lateral, medial, posterior] aspect of the right thigh.  Measurements of the hematoma are approximately [size in cm, e.g., 5 x 7 cm].  No crepitus or fluctuance noted.  Peripheral pulses are palpable and strong.  Range of motion in the right hip and knee is [limited/within normal limits] with pain reported upon [specific movements, e.g., flexion, extension].  Neurovascular assessment of the right lower extremity is intact.  Assessment: Right thigh hematoma, likely secondary to [cause].  Plan: Conservative management with RICE therapy (rest, ice, compression, elevation) is recommended.  Patient education provided regarding pain management with over-the-counter analgesics such as ibuprofen or acetaminophen.  Instructions given to monitor for signs of infection, including increasing pain, redness, warmth, or fever.  Follow-up appointment scheduled in [duration, e.g., one week] to reassess and monitor resolution of the hematoma.  Differential diagnoses considered include muscle strain, soft tissue contusion, and deep vein thrombosis, although clinical presentation is most consistent with a right thigh hematoma.  ICD-10 code: [appropriate ICD-10 code, e.g., S70.11XA] may be considered.
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