Find information on meniscus tear diagnosis, including clinical documentation tips, medical coding (ICD-10-CM, CPT) for medial and lateral meniscus tears, and healthcare resources for accurate meniscal tear documentation. Learn about common symptoms, diagnostic criteria, and treatment options for torn meniscus. This resource helps healthcare professionals ensure proper documentation and coding for meniscal injuries.
Also known as
Other meniscus derangements
Covers tears and other disorders of the meniscus.
Internal derangements of knee
Includes various knee internal problems, potentially encompassing meniscus tears.
Other knee injuries
May include unspecified meniscus injuries if not diagnosed definitively.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the meniscus tear traumatic?
Yes
Which knee?
No
Which knee?
When to use each related code
Description |
---|
Meniscal tear |
Anterior Cruciate Ligament (ACL) tear |
Medial Collateral Ligament (MCL) tear |
Coding lacks right/left side specificity, impacting reimbursement and data accuracy. Crucial for proper claims processing and analytics.
Documentation lacks detail about tear type (e.g., bucket-handle, flap) affecting accurate code assignment and DRG assignment.
Failure to distinguish traumatic vs. degenerative tear impacts code selection and can lead to inaccurate reporting and denials.
Patient presents with complaints consistent with a possible meniscus tear. Onset of symptoms occurred during (activity causing injury) approximately (duration) ago. Patient reports (localized medial or lateral) knee pain, possibly associated with a popping or clicking sensation at the time of injury. Symptoms include (severity) pain exacerbated by weight-bearing activities such as walking, squatting, and twisting. Patient also experiences (intermittent or constant) joint stiffness, swelling, and limited range of motion. Physical examination reveals tenderness to palpation along the joint line, positive McMurray test, and possible joint effusion. Differential diagnosis includes medial meniscus tear, lateral meniscus tear, meniscal injury, knee pain, knee injury, torn meniscus, cartilage damage, and other intra-articular pathology. Imaging studies, such as knee MRI or X-ray, may be indicated to confirm the diagnosis and evaluate the extent of the tear. Initial treatment plan includes RICE protocol (rest, ice, compression, elevation), NSAIDs for pain management, and physical therapy to improve strength and range of motion. Surgical intervention, such as meniscus repair or meniscectomy, may be considered if conservative treatment fails. Follow-up appointment scheduled in (duration) to assess treatment response and discuss further management options. Patient education provided regarding activity modification, bracing, and prognosis. ICD-10 codes to be considered include (appropriate codes based on laterality and type of tear e.g., S73.211A, S73.212A). CPT codes for potential procedures will be determined based on the definitive treatment plan.