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Z96.641
ICD-10-CM
Total Right Hip Replacement

Find comprehensive information on Total Right Hip Replacement diagnosis including clinical documentation requirements, medical coding guidelines, and healthcare best practices. This resource covers ICD-10-CM codes, CPT codes, postoperative care, complications, and rehabilitation for right total hip arthroplasty. Learn about accurate coding for primary and revision procedures, as well as documentation tips for optimal reimbursement. Explore relevant medical terminology and clinical indicators related to right THR for improved patient care and accurate healthcare data reporting.

Also known as

Right Total Hip Arthroplasty
Right Hip Joint Replacement

Diagnosis Snapshot

Key Facts
  • Definition : Surgical replacement of the damaged hip joint with a prosthesis.
  • Clinical Signs : Hip pain, stiffness, limited range of motion, difficulty walking.
  • Common Settings : Hospitals, outpatient surgical centers, orthopedic clinics.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC Z96.641 Coding
0SR90JZ

Total right hip replacement

Replacement of the entire right hip joint with a prosthesis.

0SRD0JZ

Revision of right hip replacement

Correction or replacement of a previously implanted right hip prosthesis.

T84.51XA

Infection of right hip prosthesis

Infection associated with a right hip replacement prosthesis.

M96.651

Mechanical complication of right hip

Mechanical problems with a right hip prosthesis or joint.

Code-Specific Guidance

Decision Tree for

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

Is this a primary or revision total hip replacement?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Total right hip replacement
Right hip revision arthroplasty
Right hip periprosthetic fracture

Documentation Best Practices

Documentation Checklist
  • Total hip replacement documentation requirements
  • Confirm diagnosis: Right hip osteoarthritis or fracture
  • Laterality: Specify right hip
  • Surgical approach documented (anterior, posterior, etc.)
  • Implant details (manufacturer, model, components)

Coding and Audit Risks

Common Risks
  • Laterality Coding Error

    Incorrect coding for right hip when procedure performed on left hip, or unspecified laterality documentation leading to coding errors.

  • Approach Documentation

    Missing documentation of surgical approach (anterior, posterior, etc.) impacting accurate DRG assignment and reimbursement.

  • Revision vs. Primary

    Failure to distinguish between primary and revision total hip replacement impacting code selection and potential under or overpayment.

Mitigation Tips

Best Practices
  • Accurate ICD-10-PCS code capture for THR: validate laterality
  • Precise CDI: document implant details, approach, and complications
  • Ensure pre-op dx, H&P support medical necessity for THR compliance
  • Timely post-op documentation of THR: progress, therapy, discharge plan
  • Query physicians for clarification on unspecified THR components for coding

Clinical Decision Support

Checklist
  • Confirm laterality: Right hip documented
  • Verify pre-op diagnosis supporting THR
  • Check operative report for implant details
  • Exclude left hip or bilateral procedures
  • Confirm post-op diagnosis: Total hip replacement

Reimbursement and Quality Metrics

Impact Summary
  • Total Right Hip Replacement reimbursement hinges on accurate ICD-10-PCS and CPT coding, impacting DRG assignment and case mix index.
  • Coding quality directly affects hospital reimbursement for total hip arthroplasty, impacting revenue cycle management and financial performance.
  • Accurate present on admission indicators for diagnoses like osteoarthritis impact right hip replacement reimbursement and quality reporting.
  • Timely and specific documentation of complications influences total hip replacement reimbursement and hospital quality metrics like readmission rates.

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 primary THR procedure
  • Verify laterality: Right hip
  • Document implant details
  • Check for complications
  • ICD-10-PCS code lookup

Documentation Templates

Patient presents with complaints of chronic right hip pain, stiffness, and limited range of motion, consistent with osteoarthritis of the right hip.  Symptoms include difficulty with ambulation, weight-bearing activities, and activities of daily living.  Conservative treatments such as physical therapy, pain management with NSAIDs, and corticosteroid injections have failed to provide adequate relief.  Radiographic imaging confirms severe degenerative changes in the right hip joint, including joint space narrowing, osteophyte formation, and subchondral sclerosis.  Diagnosis of osteoarthritis of the right hip is confirmed.  Surgical intervention in the form of a total right hip arthroplasty (total right hip replacement) is indicated.  The risks and benefits of the procedure, including potential complications such as infection, dislocation, deep vein thrombosis, and pulmonary embolism, were discussed with the patient.  The patient understands the risks and benefits and consents to the procedure.  Preoperative evaluation, including electrocardiogram and laboratory tests, will be performed.  Postoperative care plan includes physical therapy, pain management, and deep vein thrombosis prophylaxis.  Follow-up appointments will be scheduled to monitor healing and functional recovery.  ICD-10 code M16.11, right hip osteoarthritis, primary, is documented for medical billing and coding purposes.  CPT codes for total hip replacement, including component placement and surgical approach, will be determined based on the specific procedure performed.  The goal of the total right hip replacement is to alleviate pain, improve mobility, and enhance the patient's quality of life.
Total Right Hip Replacement - AI-Powered ICD-10 Documentation