Inflammation of the gluteal tendon at its attachment on the right hip, classified as a lower-limb enthesopathy under ICD-10-CM Chapter 13.

Documentation tips

What should appear in the chart to support M76.01.

Source · Editorial brief grounded in 5 cited references ↓

• Explicitly document laterality as 'right' in the assessment — 'gluteal tendinitis' without a side forces the coder to M76.00 (unspecified), which may trigger a payer edit.
• Record the mechanism or contributing factors (overuse, repetitive activity, occupation, recent increase in activity level) to support medical necessity for conservative treatment.
• If imaging was performed, document the modality (MRI, ultrasound) and relevant findings such as tendon thickening, increased signal, or partial tear to distinguish tendinitis from a full-thickness tear.
• When tendinitis coexists with trochanteric bursitis (M70.61), document both conditions separately; the Excludes2 notation permits dual coding when clinically supported.
• Note any prior conservative treatment attempts (PT, NSAIDs, activity modification) if the encounter supports a step toward injection or surgical intervention — this substantiates medical necessity.

Related CPT procedures

Procedure codes commonly billed with M76.01. 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 M76.01 and adjacent codes.

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

• Billing M76.0 (non-billable parent) or M76.00 (unspecified) instead of M76.01 when the provider's note clearly states 'right hip' — payers may reject or downcode the claim.
• Confusing gluteal tendinitis with greater trochanteric bursitis and defaulting to M70.61 (trochanteric bursitis, right hip) when the documented diagnosis is tendinitis; use the code that matches the provider's stated diagnosis.
• Coding M76.01 for a gluteal muscle tear or avulsion — tendon rupture or tear requires a different code (e.g., M66.351 for spontaneous rupture of a tendon at the right hip region).
• Ignoring the Excludes2 note and failing to separately code coexisting bursitis due to use/overuse (M70.-) when the provider documents both conditions in the same encounter.

Clinical context

Source · Editorial summary grounded in 5 cited references ↓

Sibling codes

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