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Z96.652
ICD-10-CM
Left Total Knee Arthroplasty

Find comprehensive information on Left Total Knee Arthroplasty diagnosis, including clinical documentation requirements, ICD-10-CM and CPT codes, postoperative care, and healthcare resources. This guide covers medical coding guidelines, relevant anatomy and physiology, and common complications associated with left total knee replacement surgery. Learn about proper documentation for accurate reimbursement and improved patient care. Explore resources for healthcare professionals, including coding tips and best practices for documenting Left Total Knee Arthroplasty.

Also known as

Left Knee Replacement
Left TKA

Diagnosis Snapshot

Key Facts
  • Definition : Surgical replacement of the entire knee joint with a prosthesis.
  • Clinical Signs : Severe knee pain, stiffness, swelling, limited range of motion, difficulty walking.
  • Common Settings : Hospital operating room, outpatient surgical center, orthopedic clinic.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC Z96.652 Coding
0SR90ZZ

Replacement of left knee joint

Insertion of artificial left knee joint.

0SRB0ZZ

Revision of left knee joint

Correction or replacement of existing left knee prosthesis.

T84.01XA

Mechanical complication of left knee prosthesis

Problems like loosening, dislocation, or fracture of left knee implant.

T84.89XA

Other complications of left knee prosthesis

Unspecified issues like infection or pain related to left knee implant.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is this a primary procedure?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Left Total Knee Replacement
Left Partial Knee Replacement
Left Knee Arthroplasty Complication

Documentation Best Practices

Documentation Checklist
  • Left total knee arthroplasty documentation requirements
  • Confirm laterality: surgical site specified as left knee
  • Implant details: type, size, and manufacturer documented
  • Anesthesia type and any complications recorded
  • Pre-op diagnosis supporting medical necessity of TKA

Coding and Audit Risks

Common Risks
  • Laterality Coding Error

    Incorrectly coding the right knee instead of the left or not specifying laterality, leading to claim rejections or inaccurate data.

  • Implant Specificity

    Lack of documentation specifying the type of implant used (e.g., total, partial, revision) can cause coding errors and affect reimbursement.

  • Complication Miscoding

    Intraoperative or postoperative complications may be undercoded or overcoded, impacting quality reporting and reimbursement.

Mitigation Tips

Best Practices
  • Code accurately: ICD-10-PCS 0SRD0JZ for primary, 0SRD4JZ for revision.
  • Document implant details: manufacturer, model, components for proper coding.
  • CDI: Query surgeon for clarification if documentation lacks specificity.
  • Ensure pre-op diagnosis supports medical necessity for TKA compliance.
  • Post-op: Document ROM, pain levels, complications for accurate coding.

Clinical Decision Support

Checklist
  • Verify pre-op diagnosis: Osteoarthritis, left knee
  • Confirm prior non-surgical treatments documented
  • Check left knee imaging confirms necessity for LTKA
  • Ensure patient understands risks/benefits of LTKA

Reimbursement and Quality Metrics

Impact Summary
  • Left Total Knee Arthroplasty reimbursement hinges on accurate CPT 27447 coding, impacting DRG assignment and hospital case mix index.
  • Quality metrics for Left Total Knee Arthroplasty like complication rates (surgical site infection, DVT) affect hospital value-based purchasing.
  • Timely and accurate coding of Left Total Knee Arthroplasty impacts hospital revenue cycle and reduces claim denials.
  • Documentation of functional improvements post Left Total Knee Arthroplasty influences quality reporting and patient satisfaction scores.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes. Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • Code primary 0SRG0JZ
  • Verify laterality: Left
  • Check implant details
  • Document ROM, complications
  • Exclude revisions: 0SRG3JZ

Documentation Templates

Patient presents for postoperative evaluation following left total knee arthroplasty (TKA).  The indication for surgery was severe osteoarthritis of the left knee, refractory to conservative management including physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), and viscosupplementation injections.  Preoperative diagnoses included osteoarthritis, degenerative joint disease, and chronic knee pain. The patient reports significant improvement in pain and function since the procedure.  Surgical site is well-healed, with no signs of infection, erythema, or warmth.  Range of motion is improving, currently at 0 to 110 degrees of flexion.  The patient is ambulating with a front-wheeled walker and demonstrates good stability.  Neurovascular examination is intact.  Postoperative pain is managed with oral analgesics.  Plan includes continued physical therapy for gait training, strengthening exercises, and range of motion improvement.  The patient will follow up in two weeks to monitor progress and assess wound healing.  Differential diagnosis prior to surgery included meniscus tear, ligamentous injury, and patellofemoral pain syndrome.  Current procedural terminology (CPT) code for the initial surgery was 27447.  International classification of diseases, tenth revision, clinical modification (ICD-10-CM) codes include M17.1 for primary osteoarthritis of the left knee and Z96.641 for presence of left knee prosthesis.  Patient education provided on postoperative care, activity modifications, and signs and symptoms of infection.
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