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v1.0.0
ICD-10 Guide
DiagnosesRight Buttock Pain

Right Buttock Pain

ICD-10 Coding for Right Buttock Pain(M54.31, G57.01, S39.012D)

PRIMARY SPECIALTYOrthopedics
COMPLEXITYHigh
LAST UPDATED09/15/2025
Sam Tuffun, PT, DPT
Physical Therapist | Medical Coding & Billing Contributor

Diagnosis Overview

What is Right Buttock Pain?
Essential facts and insights about Right Buttock Pain

Key Clinical Considerations:

  • Localized pain in the right buttock area
  • Radiating pain down the leg (sciatica)
  • Tenderness upon palpation of the gluteal muscles
  • Limited range of motion in hip joint
  • Possible swelling or bruising

Clinical Information

Clinical Criteria & Documentation Requirements

  • Patient history including onset, duration, and nature of pain
  • Physical examination findings including range of motion and tenderness
  • Results of imaging studies (e.g., MRI, X-ray) if performed
  • Assessment of functional limitations
  • Treatment plan and response to previous treatments

Coding Guidelines

Usage Guidelines & Examples

  • Ensure correct use of M54.16 for specific right buttock pain versus M54.9 for unspecified back pain.
  • Common errors include using general codes when specific codes are available.

Code Exclusions

Important Exclusions

  • Fractures or dislocations of the pelvis
  • Conditions like piriformis syndrome or sacroiliitis that may require different coding

Related ICD-10 Codes

Primary Codes
M54.16
Pain in right buttock
M25.55
Pain in joint, unspecified
Ancillary Codes
M51.16
M62.838
S79.011A
Differential Codes
G57.01
M54.31
M54.5

Related CPT Codes

CPT codes will be available in a future update.

Specialty Focus

Primary Specialty

Orthopedics

Specialty Applications

  • Adults experiencing musculoskeletal pain
  • Patients in outpatient orthopedic clinics

Coding Complexity

High Complexity

This diagnosis requires careful attention to:

  • Comprehensive clinical documentation
  • Accurate code selection based on clinical criteria
  • Proper exclusion considerations
  • Specialty-specific coding guidelines

Documentation

Documentation Templates

Billing Information

Billing Considerations

  • Ensure proper documentation for billing
  • Verify code specificity requirements
  • Check for any additional codes needed
  • Review payer-specific guidelines

Common Issues

  • Insufficient clinical documentation
  • Incorrect code selection
  • Missing supporting diagnoses
  • Timing and frequency documentation

Frequently Asked Questions

Documentation requirements?

Include detailed patient history, physical exam findings, and any imaging results.

Billing considerations?

Ensure accurate coding to reflect the specific diagnosis and any associated conditions.