Unilateral post-traumatic osteoarthritis, unspecified hip

This code signifies degenerative joint disease affecting a single hip, resulting from a prior injury or trauma. It indicates that the specific side (left or right) of the affected hip is not documented. The condition involves the breakdown of cartilage and bone changes within the hip joint due to the sequelae of a past physical insult.

Apply this code when documentation clearly states post-traumatic osteoarthritis of the hip, but the laterality (left or right) is not specified. This is appropriate for patients presenting with chronic hip pain, stiffness, and functional limitations directly attributable to an old injury, where the physician has not indicated which hip is affected.

• Ensure the documentation explicitly links the osteoarthritis to a prior trauma. If the trauma is not mentioned, consider primary or secondary osteoarthritis codes.
• Avoid using this code if laterality is specified (e.g., M16.51 for right, M16.52 for left); always query for laterality if missing.
• Sequence this code as a primary diagnosis when it is the reason for the encounter, or as a secondary diagnosis if it is a co-morbidity affecting treatment.