Abscess of bursa, unspecified hip

This code describes an infection with pus formation within a bursa located in the hip region, where the specific hip (right or left) is not documented. A bursa is a fluid-filled sac that reduces friction between bones, tendons, and muscles. An abscess indicates a localized collection of pus, typically due to bacterial infection.

Use this code when documentation clearly indicates an abscess of a hip bursa, but the laterality (right or left hip) is not specified. This code is appropriate when the provider's notes mention "hip bursa abscess, unspecified side" or similar phrasing. Supporting documentation includes physical exam findings of localized tenderness, swelling, erythema, and fluctuance over the hip, along with imaging (e.g., ultrasound, MRI) confirming a fluid collection consistent with an abscess.

• Avoid using this code if laterality is documented; instead, select the more specific code for right (M71.051) or left (M71.052) hip.
• Always query the provider for clarification on laterality if it is missing from the documentation.
• Code any associated infectious organism (e.g., B95-B97) as an additional diagnosis if identified.