Find information on patella dislocation diagnosis, including clinical documentation, medical coding, ICD-10 codes for patellar dislocation and subluxation, treatment, and healthcare guidelines. Learn about acute patellar dislocation, chronic patellar instability, and patellar apprehension test. Explore resources for physicians, coders, and other healthcare professionals regarding patella dislocation diagnosis and management.
Also known as
Dislocation of patella
Covers dislocations and subluxations of the patella.
Patellar dislocation and subluxation
Specifies recurrent or habitual dislocation/subluxation.
Recurrent dislocation of patella
Focuses on recurrent dislocation as a derangement of the knee.
Other injuries to knee and lower leg
May be used for unspecified patellar dislocations if necessary.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the patella dislocation traumatic?
Yes
Is it recurrent?
No
Is it atraumatic/spontaneous?
When to use each related code
| Description |
|---|
| Patella Dislocation |
| Patellar Subluxation |
| Patellofemoral Pain Syndrome |
Incorrect or missing laterality (right, left, bilateral) for patella dislocation impacts reimbursement and data accuracy. ICD-10-CM coding guidelines require specific laterality.
Distinguishing between chronic/recurrent dislocation (S83.0-) and acute/traumatic (S83.1-) is crucial for proper coding, affecting severity and treatment plans. CDI specialist query may be needed.
Failing to code associated injuries like ligament tears or fractures with patella dislocation leads to underreporting severity and missed CC/MCC capture for accurate DRG assignment.
Patient presents with complaints consistent with patellar instability or patella dislocation. Onset of symptoms occurred during (activity causing dislocation e.g., sports activity, twisting motion, direct blow) on (date of onset). Patient reports (acute or chronic) (medial or lateral) patellar pain, (feeling of popping or giving way in the knee, knee buckling, inability to bear weight). Physical examination reveals (tenderness to palpation along the medial or lateral patellar facet, swelling and edema around the knee joint, palpable effusion, limited range of motion due to pain and apprehension, positive apprehension test, positive patellar glide test). (If applicable: Previous patellar dislocation or subluxation events noted. Family history of patellar instability reported.) Imaging studies (X-ray, MRI if indicated) were ordered to confirm the diagnosis of patella dislocation and evaluate for associated injuries such as osteochondral fractures, medial patellofemoral ligament (MPFL) tears, or other ligamentous damage. Differential diagnosis includes patellofemoral pain syndrome, meniscus tear, anterior cruciate ligament (ACL) injury. Assessment: Acute (first-time) or recurrent patella dislocation (lateral, medial, or multidirectional). Treatment plan includes (initial immobilization with knee brace, pain management with NSAIDs or other analgesics, RICE protocol rest, ice, compression, elevation, referral to physical therapy for rehabilitation focusing on strengthening vastus medialis obliquus (VMO) and improving patellar tracking, potential surgical intervention such as MPFL reconstruction if conservative management fails or for recurrent dislocations). Patient education provided regarding activity modification, bracing, and rehabilitation expectations. Follow-up scheduled in ( timeframe e.g., one week, two weeks) to assess treatment response and adjust plan as needed. ICD-10 code: (Appropriate code based on laterality and chronicity e.g., S93.101A, S93.102A for acute). CPT codes for procedures performed will be documented separately.