Find information on knee joint pain diagnosis, including relevant healthcare, clinical documentation, and medical coding terms. Learn about common causes of knee pain, such as osteoarthritis, meniscus tears, ligament injuries, and patellofemoral pain syndrome. Explore diagnostic tests like physical exams, X-rays, MRI scans, and arthroscopy. Understand medical coding for knee pain diagnoses, including ICD-10 codes and CPT codes for procedures. This resource provides valuable information for healthcare professionals, clinicians, and medical coders seeking accurate and efficient documentation and coding of knee joint pain.
Also known as
Pain in knee joint
Pain localized to the knee joint.
Gonarthrosis
Degenerative joint disease of the knee.
Dislocation and sprain of knee
Includes injuries to ligaments and menisci.
Pain in limb
Pain in limb, including knee pain if not otherwise specified.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the knee pain due to trauma/injury?
Yes
Is there a fracture?
No
Is there inflammation?
When to use each related code
Description |
---|
Knee Joint Pain |
Osteoarthritis Knee |
Patellofemoral Pain Syndrome |
Coding knee pain as unspecified (M25.561) without documenting specific location or laterality risks downcoding and lost revenue.
Confusing osteoarthritis (M17) with knee pain if the documentation does not clearly establish cause-and-effect impacts accurate coding and reimbursement.
Failing to code related injuries or fractures alongside knee pain due to trauma (S89) leads to incomplete documentation and potential compliance issues.
Patient presents with knee pain, experiencing symptoms consistent with knee joint pain. Onset of pain was (gradual/acute) and began (duration) ago. The patient describes the pain as (sharp, dull, aching, throbbing, etc.) and localized to the (anterior, posterior, medial, lateral) aspect of the knee. Pain is (constant/intermittent) and aggravated by (activities such as walking, stairs, running, prolonged standing, etc.). Alleviating factors include (rest, ice, elevation, medication). Patient denies (or reports) any locking, popping, clicking, giving way, or instability. The patient reports (or denies) previous knee injuries, surgeries, or arthritis. Physical examination reveals (tenderness to palpation, swelling, erythema, warmth, range of motion limitations, crepitus, joint effusion, ligamentous instability). McMurrays and Lachman tests were (positive/negative). Differential diagnosis includes osteoarthritis, meniscus tear, ligament sprain, bursitis, patellofemoral pain syndrome, tendinitis, and referred pain. Assessment: Knee pain, likely due to (presumptive diagnosis based on history and physical exam). Plan: Conservative management with (RICE - rest, ice, compression, elevation), NSAIDs for pain relief, physical therapy referral for strengthening and range of motion exercises. Consider diagnostic imaging (X-ray, MRI) if symptoms persist or worsen. Follow-up scheduled in (duration). Patient education provided on activity modification and home exercises. Medical coding considerations include ICD-10 code for knee pain (e.g., M25.56) and CPT codes for evaluation and management (e.g., 99203-99205 for new patients, 99212-99215 for established patients), as well as any procedures performed. Further diagnostic testing or specialist referral may necessitate additional codes.