Inflammation of the psoas tendon at the hip without documented laterality — use only when the treating clinician has not specified right or left side.
Verified May 8, 2026 · 4 sources ↓
- Status
- Billable
- Chapter
- 13
- Related CPT
- 7
- Region
- Hip
Documentation tips
What should appear in the chart to support M76.10.
Source · Editorial brief grounded in 4 cited references ↓
- Record laterality explicitly — 'right hip' or 'left hip' — in the assessment or problem list so coders can use M76.11 or M76.12 instead of the unspecified M76.10.
- Distinguish psoas tendinitis from iliopsoas bursitis in the note; they require different ICD-10-CM codes (M76.1x vs. M70.- series).
- Document imaging findings (ultrasound or MRI) that support tendon pathology — thickening, increased signal, peritendinous edema — to justify the diagnosis and support medical necessity for procedures.
- Note the mechanism or contributing activity (e.g., repetitive hip flexion, running, kicking) to support clinical decision-making and potential workers' comp or activity-related payer scrutiny.
- If conservative treatment has been attempted (PT, NSAIDs, activity modification), document that history — it supports medical necessity for injection or advanced imaging referrals.
Related CPT procedures
Procedure codes commonly billed with M76.10. 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 M76.10 and adjacent codes.
Source · Editorial brief grounded in CDC ICD-10-CM tabular guidance, AAOS coding references, and cited references ↓
- Using M76.10 when laterality is actually documented elsewhere in the note — always query the chart before defaulting to unspecified.
- Coding M76.10 for iliopsoas bursitis — bursitis is coded from M70.- not M76.1x; confirm the provider's diagnosis is tendinitis, not bursitis.
- Billing the non-billable parent code M76.1 instead of the required fifth-character code (M76.10, M76.11, or M76.12) — M76.1 will reject.
- Omitting a separate code when both psoas tendinitis and iliopsoas bursitis are documented — M76 Excludes2 note means both conditions can coexist and should each be coded.
- Including the decimal point when submitting claims electronically — submit as M7610 in HIPAA transaction sets to avoid rejection.
Clinical context
Source · Editorial summary grounded in 4 cited references ↓
M76.10 captures psoas tendinitis when the affected hip has not been identified as right or left in the clinical documentation. The psoas tendon (formed by the iliacus and psoas major) inserts on the lesser trochanter of the femur; tendinopathy here typically presents as anterior hip or groin pain that worsens with hip flexion, prolonged sitting, or repetitive kicking and running activities. It falls under category M76 (Enthesopathies, lower limb, excluding foot) in ICD-10-CM Chapter 13.
Before billing M76.10, verify that laterality truly is absent from the note — not merely omitted from the assessment. If the provider documented right or left hip anywhere in the encounter, use M76.11 (right) or M76.12 (left) instead. M76.10 is a last resort, not a default. Payers and clinical auditors flag unspecified laterality codes as a specificity gap when imaging or physical exam findings are present.
Two Excludes2 notes apply at the M76 category level: bursitis due to use, overuse, and pressure (M70.-) and enthesopathies of ankle and foot (M77.5-). These are not mutually exclusive but should be coded separately if present. Do not confuse psoas tendinitis with iliopsoas bursitis — bursitis codes live in M70.- and require a different code if documented as bursitis rather than tendinitis.
Sibling codes
Other billable codes under M76.1 (laterality / anatomic variants).
Frequently asked questions
Source · Generated from the editorial pipeline, verified against 4 cited references ↓
01When is M76.10 appropriate versus M76.11 or M76.12?
02Is M76.1 billable?
03How do I code iliopsoas bursitis versus psoas tendinitis?
04What MS-DRGs does M76.10 group to?
05Can M76.10 be used as a primary diagnosis for a cortisone injection visit?
06Does M76.10 require a 7th-character extension?
07What imaging supports the psoas tendinitis diagnosis for documentation purposes?
Sources & references
Editorial content was developed using the following public sources. Last verified May 8, 2026.
Mira AI Scribe
Mira's AI scribe captures the affected side (right, left, or bilateral) from the provider's dictation, physical exam laterality findings, and any imaging reports referenced during the encounter. That laterality flag drives the code choice away from unspecified M76.10 to the specific M76.11 or M76.12 — preventing a downstream specificity denial and eliminating the need for a provider query after the visit.
See how Mira captures M76.10 documentation