Tendinous inflammation affecting the gluteal muscle insertion at the left hip, classified as an enthesopathy of the lower limb excluding foot.

Documentation tips

What should appear in the chart to support M76.02.

Source · Editorial brief grounded in 4 cited references ↓

• Document laterality explicitly as 'left' — vague terms like 'affected side' force a drop to M76.00 (unspecified), which triggers payer scrutiny.
• Record the involved tendon(s) by name (gluteus medius, gluteus minimus, or both) and the anatomic insertion site (greater trochanter) to support clinical specificity.
• Include imaging findings when available — ultrasound or MRI evidence of tendon thickening, peritendinous fluid, or entheseal calcification strengthens medical necessity for injection or physical therapy authorization.
• If trochanteric bursitis is also present and independently treated, document it as a separate finding to justify dual coding with M70.62.
• Capture conservative care history (physical therapy, NSAIDs, activity modification) before injection authorization; many payers require this for step-therapy compliance.

Related CPT procedures

Procedure codes commonly billed with M76.02. 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 M76.02 and adjacent codes.

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

• Billing parent code M76.0 instead of the laterality-specific child code — M76.0 is non-billable and will reject for reimbursement.
• Confusing gluteal tendinitis (M76.02) with trochanteric bursitis (M70.62) — they are distinct diagnoses with separate codes; use both only when both are documented and treated.
• Using M76.00 (unspecified hip) when the provider note clearly states 'left' — always assign the specific laterality code when laterality is documented.
• Omitting a secondary code for the underlying cause (e.g., gait abnormality, leg length discrepancy) when the provider attributes the tendinitis to a mechanical etiology — those comorbid codes can support medical necessity.

Clinical context

Source · Editorial summary grounded in 4 cited references ↓

Sibling codes

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