Find information on knee pain diagnosis, including clinical documentation, medical coding, and healthcare resources. This guide covers common knee pain symptoms, differential diagnosis considerations, ICD-10 codes for knee pain (e.g., pain in knee joint, patellofemoral pain syndrome), and relevant medical terminology for accurate documentation. Learn about evaluating knee pain, diagnostic tests, and treatment options. Explore resources for healthcare professionals related to knee pain management and coding best practices.
Also known as
Pain in knee
Pain localized to the knee joint.
Injuries to the knee and lower leg
Includes fractures, sprains, and other injuries around the knee.
Arthrosis
Degenerative joint diseases, including knee osteoarthritis, can cause pain.
Diseases of the musculoskeletal system and connective tissue
Broader category encompassing various conditions causing knee pain.
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 pain, unspecified |
Patellofemoral pain syndrome |
Knee osteoarthritis |
Coding knee pain with unspecified codes (e.g., M25.56) when more specific diagnoses are documented leads to inaccurate severity reflection and reimbursement.
Incorrectly coding lateral (outer) or medial (inner) knee pain can impact treatment plans and lead to denials for laterality-specific procedures.
Failing to distinguish between traumatic knee pain (e.g., S72.1XXA) and chronic conditions (e.g., M25.561) impacts data accuracy and case mix index.
Patient presents with knee pain, the chief complaint being [character of pain: e.g., sharp, dull, aching, throbbing] localized to the [location of pain: e.g., medial, lateral, anterior, posterior] aspect of the [right or left] knee. Onset of pain was [onset: e.g., gradual, sudden] [timeframe: e.g., two weeks ago, following a fall yesterday]. Pain is aggravated by [aggravating factors: e.g., weight-bearing, stairs, prolonged standing] and relieved by [relieving factors: e.g., rest, ice, elevation]. Patient denies any locking, clicking, or giving way. Associated symptoms include [associated symptoms: e.g., stiffness, swelling, warmth, redness, limited range of motion]. Patient's past medical history includes [past medical history: e.g., osteoarthritis, rheumatoid arthritis, previous knee injury]. Medications include [medications: e.g., ibuprofen, acetaminophen]. Allergies include [allergies: e.g., none, penicillin]. Physical examination reveals [physical exam findings: e.g., tenderness to palpation over the medial joint line, mild effusion, full range of motion with pain at end range of flexion]. Differential diagnosis includes [differential diagnosis: e.g., osteoarthritis, meniscus tear, ligament sprain, patellofemoral pain syndrome]. Assessment: Knee pain, likely due to [likely diagnosis: e.g., osteoarthritis]. Plan: [Plan: e.g., Recommend conservative management including rest, ice, compression, elevation. Prescribed ibuprofen 800mg every 8 hours as needed for pain. Referred to physical therapy. Follow-up in 2 weeks to reassess. If symptoms worsen, consider MRI of the knee].