Patient presents with complaints consistent with internal derangement of the knee.  Onset of symptoms described as (acute or insidious) following (mechanism of injury if applicable, e.g., twisting injury, direct blow, or no specific event).  Patient reports (specific symptoms, e.g., pain, clicking, popping, catching, locking, swelling, instability, giving way) localized to (medial, lateral, anterior, or posterior knee).  Pain is characterized as (quality of pain, e.g., sharp, dull, aching, throbbing) and (severity of pain on a scale of 0-10).  Symptoms are (aggravated by, e.g., weight-bearing, twisting, certain activities) and (relieved by, e.g., rest, ice, elevation, medication).  Physical examination reveals (positive or negative) tenderness to palpation along the (joint line, medial joint line, lateral joint line, patellofemoral joint).  Range of motion is (limited or within normal limits) with (degrees of flexion and extension).  (Specific special tests, e.g., McMurray test, Lachman test, Anterior Drawer test, Posterior Drawer test) were performed and found to be (positive or negative).  Differential diagnosis includes meniscus tear, ligament injury (ACL tear, PCL tear, MCL tear, LCL tear), patellar instability, loose body, plica syndrome, and osteoarthritis.  Assessment:  Internal derangement of the knee, likely (specify suspected structure involved, e.g., meniscus, ligament, cartilage).  Plan:  (Conservative management including rest, ice, compression, elevation, physical therapy, NSAIDs or surgical intervention if indicated).  Follow-up scheduled in (timeframe) to reassess symptoms and functional status.  ICD-10 code M23.3X (specify laterality) and CPT codes for evaluation and management (e.g., 9920X, 9921X) are documented.