Unilateral primary osteoarthritis, unspecified hip

This code signifies a degenerative joint disease affecting one hip, where the cause is not secondary to another condition (e.g., trauma, infection). It involves the breakdown of cartilage and underlying bone in a single hip joint, leading to pain, stiffness, and reduced range of motion, without a specified laterality.

Use this code when documentation indicates primary osteoarthritis affecting only one hip, but the specific side (left or right) is not documented. This is appropriate for initial diagnoses or follow-up visits where the laterality remains unstated. Supporting documentation includes physician notes describing unilateral hip pain, imaging reports showing osteoarthritic changes in one hip, and the absence of a secondary cause.

• Avoid using this code if the documentation clearly specifies left or right hip; instead, use the more specific codes (M16.11 or M16.12).
• Ensure the "primary" nature of the osteoarthritis is supported; if a secondary cause is identified, a different code from the M16.2-M16.5 series would be more appropriate.
• This code should be sequenced as the primary diagnosis when the osteoarthritis is the main reason for the encounter.