Understanding Bilateral Knee Replacement (Bilateral TKA or Bilateral Total Knee Arthroplasty) diagnosis? This resource provides information on healthcare, clinical documentation, and medical coding for Bilateral Knee Replacement. Find details on appropriate medical terms and coding guidelines relevant to Bilateral TKA procedures for accurate and efficient medical record keeping.
Also known as
Replacement of right and left knee joint
Codes for bilateral total knee replacement surgery.
Replacement of right knee joint
May be relevant if coding each knee separately.
Replacement of left knee joint
May be relevant if coding each knee separately.
Complications of knee joint prosthesis
For post-surgical complications, not the initial procedure.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is this an initial encounter?
Yes
Routine or other aftercare?
No
Code Z96.641, Presence of bilateral knee joint replacement
When to use each related code
| Description |
|---|
| Both knees replaced with prostheses. |
| One knee replaced with prosthesis. |
| Knee pain without replacement. |
Incorrect coding for bilateral procedures can lead to underpayment or claim denial. Ensure proper laterality modifiers are used (e.g., -50, -LT, -RT).
Lack of documentation specifying the type of implant used can affect accurate DRG assignment and reimbursement. CDI should query for implant details.
Missing documentation of comorbidities or complications (e.g., infection, DVT) impacts severity level and can result in lower reimbursement.
Q: What are the evidence-based best practices for minimizing post-operative complications in simultaneous bilateral total knee arthroplasty?
A: Minimizing post-operative complications in simultaneous bilateral total knee arthroplasty (BTKA) requires a multi-faceted approach. Pre-operatively, patient optimization is crucial, focusing on factors like diabetes control, smoking cessation, and nutritional status. Intra-operatively, meticulous surgical technique, including proper component alignment and soft tissue balancing, is essential. Post-operatively, a multimodal pain management regimen that minimizes opioid use, alongside early mobilization and a robust physical therapy program, can significantly reduce complications like DVT, infection, and stiffness. Explore how implementing a standardized post-operative protocol can improve patient outcomes after bilateral TKA.
Q: How do I determine patient candidacy for bilateral vs. staged unilateral knee replacement surgery, considering factors like comorbidities and functional status?
A: Choosing between bilateral and staged unilateral knee replacement hinges on a comprehensive patient assessment. While bilateral knee replacement offers the advantage of a single recovery period, it presents increased physiological stress and is generally more suitable for patients with fewer comorbidities and good overall health. Patients with significant cardiac, pulmonary, or renal issues might be better suited for staged unilateral procedures to minimize perioperative risk. Functional status plays a vital role as well. Patients with limited pre-operative mobility may find the rehabilitation after bilateral knee replacement more challenging. Consider implementing a decision-making algorithm that incorporates patient-reported outcomes and objective functional tests to guide surgical planning. Learn more about the specific benefits and drawbacks of each approach.
Patient presents with chronic bilateral knee pain, stiffness, and functional limitation, consistent with severe osteoarthritis. The patient reports a history of progressively worsening pain, impacting activities of daily living such as walking, stair climbing, and standing. Conservative treatments including physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), and viscosupplementation have failed to provide adequate relief. Physical examination reveals bilateral crepitus, reduced range of motion, and tenderness to palpation. Radiographic imaging confirms advanced degenerative joint disease in both knees, characterized by joint space narrowing, osteophyte formation, and subchondral sclerosis. After discussing the risks and benefits of surgical intervention, the patient elects to proceed with bilateral total knee arthroplasty. Diagnosis: Bilateral knee replacement (Bilateral TKA). Treatment plan includes preoperative medical clearance, surgical scheduling for bilateral total knee arthroplasty, and postoperative rehabilitation focusing on pain management, range of motion improvement, and functional restoration. ICD-10 code M17.0 for primary gonarthrosis, bilateral will be utilized for medical billing and coding purposes. Prognosis for improved mobility and pain reduction is good with appropriate postoperative care and adherence to the prescribed rehabilitation program. The patient will be scheduled for a follow-up appointment to assess surgical outcomes and progress with physical therapy.