Osteoarthritis unilateral or bilateral

Created Apr 2011
Reviewed Dec 2019

Query

A patient is admitted for a total hip joint replacement of the left hip after having had the right hip replaced two years earlier.  What osteoarthritis code should be assigned, unilateral or bilateral?

Response

Assign the diagnosis code for unilateral osteoarthritis M16.1 Other primary coxarthrosis with an additional diagnosis for the hip replacement status Z96.64 Presence of right hip implant as the osteoarthritis of the right hip has been eradicated.

Documentation of ‘arthrosis’, ‘osteoarthrosis’ or ‘osteoarthritis’ with no underlying condition identified as the cause, should be assigned the relevant code for ‘primary’.

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