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S83.419A
ICD-10-CM
MCL Sprain

Find information on MCL sprain diagnosis, including clinical documentation, medical coding, and healthcare guidelines. Learn about medial collateral ligament injury, knee sprain evaluation, and treatment options. This resource covers ICD-10 codes for MCL sprain, accurate diagnosis coding, and documentation best practices for healthcare professionals. Explore relevant information on knee instability, ligament tear, and orthopedic examination for MCL sprains.

Also known as

Medial Collateral Ligament Sprain
Knee MCL Injury

Diagnosis Snapshot

Key Facts
  • Definition : Tear or stretch of the medial collateral ligament (MCL) in the knee.
  • Clinical Signs : Inner knee pain, swelling, stiffness, instability, sometimes a popping sound at injury.
  • Common Settings : Sports injuries, direct blows to the outer knee, twisting injuries.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC S83.419A Coding
S83.4

Sprain of medial collateral ligament of knee

Injury to the MCL, a knee ligament providing stability.

S83

Sprain and strain of knee and leg

Includes various ligament and muscle injuries around the knee.

S80-S89

Injuries to the knee and lower leg

Encompasses a wider range of knee and lower leg injuries.

Code-Specific Guidance

Decision Tree for

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

Which knee is affected?

  • Right

    Is it a complete tear?

  • Left

    Is it a complete tear?

  • Unspecified

    Is it a complete tear?

Code Comparison

Related Codes Comparison

When to use each related code

Description
MCL Sprain
LCL Sprain
Meniscus Tear

Documentation Best Practices

Documentation Checklist
  • MCL sprain diagnosis documentation: laterality, severity
  • Physical exam: tenderness, laxity, ROM, swelling
  • Mechanism of injury: valgus stress, trauma details
  • Imaging: X-ray (rule out fx), MRI if needed
  • ICD-10 code: specify S83.4XXA/D/S as appropriate

Coding and Audit Risks

Common Risks
  • Unspecified Laterality

    Coding MCL sprain without specifying left or right knee leads to claim denials and inaccurate data reporting. Use S83.401A/S83.402A for right or left respectively.

  • Grade I Miscoding

    Often documented as a strain, a grade I MCL sprain is a S83.4 code. Miscoding with strain codes impacts reimbursement and quality metrics.

  • Unclear Documentation

    Vague documentation like knee pain or instability without explicit MCL sprain diagnosis hinders accurate code assignment and may trigger audits.

Mitigation Tips

Best Practices
  • Document MCL sprain laterality, grade, and mechanism for accurate ICD-10 coding.
  • Use precise CDI queries for MCL tear vs. sprain to ensure compliant billing.
  • Correlate physical exam findings with imaging results for optimal medical necessity.
  • Specify treatment plan (conservative vs. surgical) for HCC risk adjustment accuracy.
  • Ensure documentation supports medical necessity of DME like knee braces for compliance.

Clinical Decision Support

Checklist
  • Valgus stress test laxity at knee
  • Medial joint line tenderness
  • Absence of significant effusion hemarthrosis
  • Pain with valgus stress 0-5 degrees
  • Consider MRI if other pathology suspected

Reimbursement and Quality Metrics

Impact Summary
  • MCL Sprain reimbursement hinges on accurate coding (ICD-10 S83.4-) and documentation of severity.
  • Coding errors impact MCL Sprain reimbursement and denials. Proper laterality (right/left) crucial.
  • Quality metrics for MCL Sprain track return to function, pain levels, and patient satisfaction.
  • Timely and accurate reporting of MCL Sprain diagnoses improves hospital quality scores and revenue.

Streamline Your Medical Coding

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

Quick Tips

Practical Coding Tips
  • Code MCL sprain with laterality
  • Specify partial/complete tear
  • Document mechanism of injury
  • Include instability grade if applicable
  • Consider associated meniscus codes

Documentation Templates

Patient presents with complaints of medial knee pain consistent with a suspected MCL sprain.  Onset of pain occurred on [Date of injury] during [Mechanism of injury - e.g., playing soccer, twisting knee while stepping off a curb].  Patient reports [Character of pain - e.g., sharp, aching, throbbing] pain localized to the medial aspect of the knee, exacerbated by [Exacerbating factors - e.g., weight-bearing, valgus stress].  Patient denies any popping or clicking sensations.  Physical examination reveals [Tenderness to palpation along MCL, presence or absence of effusion, range of motion limitations].  Valgus stress test at [Degrees of flexion] elicits [Pain, laxity - Grade I, II or III based on laxity].  McMurray's test is negative for meniscus tear.  Differential diagnosis includes meniscus tear, medial plica syndrome, and pes anserine bursitis.  Assessment: Medial collateral ligament sprain, [Grade I, II, or III].  Plan:  RICE therapy (rest, ice, compression, elevation) is recommended.  Prescribed NSAIDs for pain and inflammation management.  Patient educated on activity modification and provided with a knee brace for stabilization.  Follow-up scheduled in [Timeframe - e.g., 1-2 weeks] to assess response to treatment. Referral to physical therapy will be considered based on progress.  ICD-10 code: [Appropriate ICD-10 code - e.g., S13.411A for Sprain of medial collateral ligament of right knee, initial encounter].
MCL Sprain - AI-Powered ICD-10 Documentation