What is the ICD-10 (International Classification of Diseases, 10th Revision) code for a female patient with menopausal gluteal tendinopathy?

ICD-10 Code for Menopausal Gluteal Tendinopathy

The ICD-10 code for gluteal tendinopathy in a menopausal woman is M76.00 (Gluteal tendinitis, unspecified hip) or M76.01/M76.02 for right or left hip specifically.

Primary Diagnostic Code

• M76.00 is the appropriate code for gluteal tendinitis/tendinopathy when laterality is not specified 1
• M76.01 should be used for right gluteal tendinopathy 1
• M76.02 should be used for left gluteal tendinopathy 1

Important Coding Considerations

• The term "tendinitis" in ICD-10 coding encompasses both acute inflammatory and chronic degenerative tendon conditions (tendinopathy/tendinosis), despite the pathophysiology being primarily degenerative rather than inflammatory in most cases 2, 3
• Gluteal tendinopathy is the most prevalent lower limb tendinopathy, affecting 1 in 4 women older than 50 years, with particular prevalence in postmenopausal women 4, 5

Additional Relevant Codes to Consider

• If the patient has documented osteoporosis or is at risk (common in postmenopausal women with gluteal tendinopathy), consider also coding:
  • M81.0 for age-related osteoporosis without current pathological fracture 1
  • Z79.83 if the patient is on long-term hormone replacement therapy 6
• N95.1 can be added as a secondary code for menopausal and female climacteric states if vasomotor or other menopausal symptoms are being actively managed 6

Clinical Context

• Greater trochanteric pain syndrome (GTPS), now recognized as primarily gluteal tendinopathy rather than trochanteric bursitis, is believed to originate from age-related degenerative changes about the hip abductor tendon insertions, exacerbated by hormonal changes after menopause 4, 5
• The condition causes debilitating lateral hip pain and dysfunction, particularly in postmenopausal women in their fifth and sixth decades of life 4, 7