Find information on knee sprain diagnosis, including clinical documentation, medical coding, ICD-10 codes, and treatment. Learn about the different grades of knee sprains, lateral collateral ligament sprain, medial collateral ligament sprain, and anterior cruciate ligament injuries. This resource provides guidance for healthcare professionals on proper documentation and coding for knee sprain injuries for accurate reimbursement and patient care. Explore knee sprain symptoms, causes, and diagnostic tests.
Also known as
Sprains and strains of knee and leg
Covers sprains and strains affecting the knee and leg area.
Injuries to the knee and lower leg
Includes various injuries like fractures, dislocations, and sprains in the knee and lower leg.
Internal derangements of knee
Includes internal knee problems like meniscus tears that may accompany a sprain.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the knee sprain traumatic?
Yes
Current injury?
No
Consider other diagnoses. Sprain is by definition traumatic. Review documentation for alternative diagnosis or clarification.
When to use each related code
Description |
---|
Knee ligament stretch or tear |
Knee meniscus tear |
Knee contusion |
Coding knee sprain without specifying right, left, or bilateral can lead to claim denials and inaccurate reporting. Use ICD-10 laterality codes.
Lack of documentation specifying which ligament is sprained (MCL, LCL, ACL, PCL) leads to coding errors and impacts severity reflection.
Incorrectly coding a tear or strain as a sprain or vice-versa, based on vague documentation, leads to inaccurate severity and reimbursement.
Patient presents with complaints consistent with a knee sprain. Onset of symptoms occurred on [Date of onset] following [Mechanism of injury - e.g., twisting injury while playing basketball, fall]. Patient reports [Character of pain - e.g., sharp, aching] pain localized to the [Location of pain - e.g., medial aspect of the right knee, lateral left knee]. Pain is aggravated by [Aggravating factors - e.g., weight-bearing, flexion]. Patient denies any popping or clicking sensations. Physical examination reveals [Objective findings - e.g., tenderness to palpation along the medial joint line, mild effusion, full range of motion with some discomfort at end range]. Ligamentous testing demonstrates [Results of ligamentous tests - e.g., negative anterior drawer and Lachman tests, positive valgus stress test at 30 degrees]. No obvious deformity or crepitus noted. Neurovascular examination is intact. Assessment: Knee sprain, likely [Grade of sprain - e.g., Grade I, Grade II] of the [Specific ligament involved - e.g., medial collateral ligament]. Differential diagnoses include meniscus tear, patellar subluxation, and fracture. Plan: RICE protocol (rest, ice, compression, elevation) is recommended. Patient advised to avoid weight-bearing as tolerated and use crutches as needed. NSAIDs prescribed for pain management. Referral to physical therapy for rehabilitation. Follow-up scheduled in [Duration - e.g., one week] to assess progress. ICD-10 code: [Appropriate ICD-10 code - e.g., S83.401A Sprain of unspecified part of right knee, initial encounter].