Pseudocoxalgia, unspecified hip

This code represents a non-specific diagnosis of pseudocoxalgia, also known as Legg-Calvé-Perthes disease (LCPD), when the laterality of the affected hip is not documented. It indicates avascular necrosis of the femoral head in a pediatric patient, leading to collapse and deformity, without specifying if it's the right or left hip.

Use this code when the medical record clearly indicates a diagnosis of pseudocoxalgia or LCPD, but the physician documentation does not specify which hip is affected. This code is appropriate when initial diagnostic workup is underway or when the laterality is simply not recorded.

• Always query the provider for laterality (right or left) if not documented to allow for a more specific code assignment.
• Avoid using this code if documentation specifies unilateral or bilateral involvement; instead, use M91.31 (right), M91.32 (left), or M91.33 (bilateral).
• This code should be sequenced as the primary diagnosis when pseudocoxalgia is the reason for the encounter.