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
Sprain of medial collateral ligament of knee
Injury to the MCL, a knee ligament providing stability.
Sprain and strain of knee and leg
Includes various ligament and muscle injuries around the knee.
Injuries to the knee and lower leg
Encompasses a wider range of knee and lower leg injuries.
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?
When to use each related code
Description |
---|
MCL Sprain |
LCL Sprain |
Meniscus Tear |
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.
Often documented as a strain, a grade I MCL sprain is a S83.4 code. Miscoding with strain codes impacts reimbursement and quality metrics.
Vague documentation like knee pain or instability without explicit MCL sprain diagnosis hinders accurate code assignment and may trigger audits.
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].