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S83.209A
ICD-10-CM
Meniscal Tear

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

Meniscus Tear
Torn Meniscus

Diagnosis Snapshot

Key Facts
  • Definition : A rip or tear in the meniscus, the cartilage cushioning the knee joint.
  • Clinical Signs : Knee pain, swelling, stiffness, popping or clicking sensation, difficulty straightening the knee, feeling of the knee giving way.
  • Common Settings : Sports injuries, twisting motions, degenerative changes, direct trauma to the knee.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC S83.209A Coding
S83.2-

Other meniscus derangements

Covers tears and other disorders of the meniscus.

M23.-

Internal derangements of knee

Includes various knee internal problems, potentially encompassing meniscus tears.

S83.9-

Other knee injuries

May include unspecified meniscus injuries if not diagnosed definitively.

Code-Specific Guidance

Decision Tree for

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

Is the meniscus tear traumatic?

  • Yes

    Which knee?

  • No

    Which knee?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Meniscal tear
Anterior Cruciate Ligament (ACL) tear
Medial Collateral Ligament (MCL) tear

Documentation Best Practices

Documentation Checklist
  • Meniscal tear diagnosis: Document laterality (left/right)
  • Meniscal tear: Specify location (medial/lateral/posterior horn)
  • Document mechanism of injury: Traumatic vs. Degenerative
  • Meniscal tear: Include any prior injuries/surgeries
  • ICD-10 code M23.2*: Specify 5th character for laterality

Coding and Audit Risks

Common Risks
  • Unspecified Laterality

    Coding lacks right/left side specificity, impacting reimbursement and data accuracy. Crucial for proper claims processing and analytics.

  • Missing Acuity Detail

    Documentation lacks detail about tear type (e.g., bucket-handle, flap) affecting accurate code assignment and DRG assignment.

  • Trauma vs. Degenerative

    Failure to distinguish traumatic vs. degenerative tear impacts code selection and can lead to inaccurate reporting and denials.

Mitigation Tips

Best Practices
  • Document mechanism of injury, location, and type of tear for accurate ICD-10 coding (S83.-)
  • Use precise MRI documentation for accurate diagnosis coding and compliance with payer guidelines.
  • Clearly document McMurrays and Thessaly test results for improved CDI and justification of medical necessity.
  • Specify meniscus tear (medial/lateral, anterior/posterior horn) for optimal CPT coding accuracy during arthroscopy.
  • Correlate clinical findings, imaging results, and prior history to avoid denials and ensure compliant billing.

Clinical Decision Support

Checklist
  • Hx: twisting injury, popping sensation, joint locking (ICD-10: S73.2)
  • Exam: joint line tenderness, McMurray's test, Thessaly test (SNOMED CT: 41928003)
  • Imaging: MRI for confirmation (CPT: 73721), assess ligaments
  • Dx: Specify location, type (medial/lateral, bucket-handle) for accurate coding

Reimbursement and Quality Metrics

Impact Summary
  • Meniscal Tear Reimbursement: CPT codes (29880-29883) drive payment. Accurate laterality and procedure coding crucial for maximizing reimbursement.
  • Coding Accuracy Impact: Miscoding (e.g., using 71700 for MRI instead of 73721 with contrast) impacts claim denial rates and delays payment.
  • Hospital Reporting Metrics: Meniscal tear diagnosis affects AR days, Case Mix Index (CMI), and overall hospital financial performance. Accurate coding is essential for optimal reporting.
  • Quality Metrics Impact: Post-op complications like stiffness or infection impact quality scores. Thorough documentation crucial for risk adjustment.

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
  • Lateral/Medial meniscus ICD-10 code
  • Document tear type/location
  • MRI confirms, code M73.2x

Documentation Templates

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.