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M25.461
ICD-10-CM
Right Knee Effusion

Find information on right knee effusion diagnosis, including clinical documentation, medical coding (ICD-10 M25.461, M25.469), and healthcare guidance. Learn about symptoms, causes, and treatment options for fluid on the knee, including diagnostic tests like arthrocentesis and MRI. Explore resources for accurate medical coding and proper documentation of right knee effusion for optimal reimbursement. Understand the clinical significance of right knee swelling and pain related to effusion.

Also known as

Knee Joint Effusion
Fluid on the Knee

Diagnosis Snapshot

Key Facts
  • Definition : Swelling from excess fluid in the right knee joint.
  • Clinical Signs : Pain, stiffness, limited range of motion, visible swelling.
  • Common Settings : Sports injuries, arthritis, trauma, overuse, infection.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC M25.461 Coding
M25.461

Swelling of right knee

Effusion (fluid buildup) within the right knee joint.

M17

Gonarthrosis

Osteoarthritis of knee, a common cause of knee effusion.

S70-S79

Injuries to the knee and lower leg

Traumatic injuries can cause right knee effusion.

M00-M25

Arthropathies

Various joint diseases, some of which cause knee effusions.

Code-Specific Guidance

Decision Tree for

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

Is the effusion traumatic?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Right Knee Effusion
Right Knee Osteoarthritis
Right Knee Meniscus Tear

Documentation Best Practices

Documentation Checklist
  • Document laterality (right knee)
  • Effusion size/severity (mild, moderate, severe)
  • Palpation findings (warmth, tenderness, fluctuance)
  • Range of motion limitations if present
  • Associated symptoms (pain, stiffness, locking)

Coding and Audit Risks

Common Risks
  • Unspecified Effusion

    Coding unspecified effusion (M25.461) without documenting the cause can lead to claim denials and lower reimbursement.

  • Trauma vs. Non-Trauma

    Incorrectly coding traumatic (S18.101A) vs. non-traumatic effusion impacts severity and reimbursement. Clear documentation is crucial.

  • Laterality Missing

    Failing to document laterality (right knee) with effusion code (M25.461) causes coding errors and claim rejections.

Mitigation Tips

Best Practices
  • Document laterality, effusion size, and cause (ICD-10 M25.46, M25.47).
  • Specify if effusion is symptomatic for accurate coding, billing (HCCs).
  • Correlate imaging, aspiration findings with exam for CDI, compliance.
  • Use standardized terminology (e.g., mild, moderate, severe) in notes.
  • Query physician for clarity if documentation lacks detail for coding.

Clinical Decision Support

Checklist
  • 1. Verify pain, swelling, stiffness in right knee.
  • 2. Palpate for warmth, tenderness, range of motion limitations.
  • 3. Document size, location of effusion. Consider McMurray's test.
  • 4. Order imaging (e.g., X-ray, ultrasound, MRI) as indicated.
  • 5. R/O trauma, infection, inflammatory arthritis. Document DDx.

Reimbursement and Quality Metrics

Impact Summary
  • Right Knee Effusion reimbursement hinges on accurate ICD-10 (M25.46) and CPT coding for aspiration, injection, or other procedures.
  • Coding errors for Right Knee Effusion impact hospital revenue cycle, denials, and overall financial performance.
  • Quality metrics like patient satisfaction and pain management are crucial for Right Knee Effusion treatment success.
  • Proper documentation of effusion severity and treatment plan affects reimbursement and quality reporting accuracy.

Streamline Your Medical Coding

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

Quick Tips

Practical Coding Tips
  • Code M25.461, M25.462, or M25.469
  • Specify laterality: right knee
  • Document effusion cause if known
  • Consider 717.86 for aspiration
  • ICD-10, knee effusion, coding

Documentation Templates

Patient presents with complaints of right knee pain, swelling, and stiffness, consistent with right knee effusion.  Onset of symptoms reported as [duration] and attributed to [cause of effusion if known, e.g., trauma during basketball game, insidious onset].  Patient denies fever, chills, or systemic symptoms.  Physical examination reveals noticeable right knee swelling compared to the contralateral knee.  Palpation elicits tenderness along the [specify location, e.g., medial joint line, patellofemoral joint] and positive for [relevant physical exam findings, e.g., patellar tap, bulge sign].  Range of motion is restricted due to pain and swelling, measured at [degrees of flexion and extension].  Differential diagnosis includes meniscal tear, ligament injury, osteoarthritis, and inflammatory arthritis.  Plan includes right knee X-ray to evaluate for bony abnormalities, joint space narrowing, and other underlying pathology.  Depending on imaging results, further evaluation with MRI or aspiration of the right knee joint may be indicated.  Patient education provided on RICE therapy (Rest, Ice, Compression, Elevation) and NSAIDs for pain management.  Follow-up scheduled in [duration] to reassess symptoms and discuss further management options depending on imaging and response to conservative treatment.  ICD-10 code: [appropriate ICD-10 code, e.g., M25.461].