Find information on Unilateral Primary Osteoarthritis Right Hip diagnosis, including clinical documentation, medical coding, ICD-10-CM code M16.11, and healthcare guidance. Learn about symptoms, treatment, and management of right hip osteoarthritis. This resource offers support for accurate medical coding and comprehensive clinical documentation for healthcare professionals. Explore details on unilateral hip osteoarthritis and optimize your medical records for accurate billing and diagnosis reporting.
Also known as
Coxarthrosis
Degenerative joint disease of the hip.
Arthroses
Joint disorders primarily affecting cartilage.
Diseases of the musculoskeletal system and connective tissue
Encompasses various conditions affecting bones, joints, and connective tissues.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is osteoarthritis primary?
Yes
Is it unilateral?
No
Post-traumatic?
When to use each related code
| Description |
|---|
| Right hip osteoarthritis |
| Right hip osteoarthritis with inflammation |
| Right hip post-traumatic osteoarthritis |
Incorrectly coding the affected side as left hip or unspecified, leading to inaccurate data and claims.
Failing to capture the primary nature of the osteoarthritis or the absence of trauma, resulting in lower reimbursement.
Overlooking associated conditions like pain or inflammation that impact severity and treatment, affecting quality reporting.
Patient presents with complaints of right hip pain, stiffness, and limited range of motion, consistent with a clinical presentation of unilateral primary osteoarthritis of the right hip. Symptoms include localized right hip joint pain exacerbated by weight-bearing activities and prolonged standing, morning stiffness lasting less than 30 minutes, and crepitus with movement. The patient denies any history of trauma, infection, or inflammatory arthritis. Physical examination reveals tenderness to palpation over the right hip joint, reduced internal and external rotation, and painful passive range of motion. Radiographic imaging of the right hip demonstrates joint space narrowing, osteophyte formation, and subchondral sclerosis, confirming the diagnosis of osteoarthritis. No evidence of other joint involvement is observed. Differential diagnoses considered included avascular necrosis, labral tear, and trochanteric bursitis. These were ruled out based on clinical findings and imaging results. The patient's pain is currently managed with over-the-counter analgesics, and they have been educated on activity modification and weight management. A referral to physical therapy has been made for range of motion exercises and strengthening. Conservative management will be continued, with consideration for intra-articular corticosteroid injections or hip replacement surgery if symptoms persist or worsen. ICD-10 code M16.01 is appropriate for this diagnosis. Follow-up appointment scheduled in four weeks to assess response to treatment and discuss further management options.