Inflammation of the gluteal tendon at its enthesis (bone-to-tendon attachment) at the hip, coded when the treating clinician has not specified whether the right or left hip is involved.

Documentation tips

What should appear in the chart to support M76.00.

Source · Editorial brief grounded in 6 cited references ↓

• Document affected side by name (right or left) in every note — this single element upgrades M76.00 to M76.01 or M76.02 and satisfies specificity requirements.
• Specify which gluteal tendon is involved (gluteus medius, minimus, or maximus) and the anatomic attachment site (e.g., greater trochanteric facet) to support medical necessity for imaging or injection.
• Record imaging findings that confirm tendinopathy — MRI signal change, tendon thickening, or partial tearing — and cite Kellgren-Lawrence or similar grading if concurrent hip OA is present.
• Note the conservative care already attempted (physical therapy, NSAIDs, activity modification) when documenting medical necessity for corticosteroid or PRP injection.
• If trochanteric bursitis coexists, document both diagnoses explicitly so both M76.0x and the appropriate M70.6x code can be reported without creating an Excludes conflict.

Related CPT procedures

Procedure codes commonly billed with M76.00. Linking the right diagnosis to the right procedure is what establishes medical necessity.

Source · CMS LCDs · AAOS specialty guidance · claims-pattern analysis

Common coding pitfalls

The recurring mistakes coders make with M76.00 and adjacent codes.

Source · Editorial brief grounded in CDC ICD-10-CM tabular guidance, AAOS coding references, and cited references ↓

• Billing M76.00 when the note clearly states 'right' or 'left' hip — always assign M76.01 or M76.02 when laterality is documented; unspecified codes invite downcoding or medical necessity denials.
• Confusing gluteal tendinitis (M76.0x) with trochanteric bursitis (M70.6x) — they are distinct diagnoses under different code families; do not substitute one for the other based on anatomic proximity alone.
• Coding M76.0 (parent) instead of M76.00 — M76.0 is non-billable and will reject; only the five-character child codes (M76.00, M76.01, M76.02) are valid for claim submission.
• Omitting an external cause code when the tendinitis is occupational or activity-related, which can affect workers' compensation and liability payer adjudication.
• Appending a 7th-character extension (A, D, or S) to M76.00 — these extensions do not apply to M-code enthesopathy diagnoses.

Clinical context

Source · Editorial summary grounded in 6 cited references ↓

Sibling codes

Other billable codes under M76.0 (laterality / anatomic variants).