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
Swelling of right knee
Effusion (fluid buildup) within the right knee joint.
Gonarthrosis
Osteoarthritis of knee, a common cause of knee effusion.
Injuries to the knee and lower leg
Traumatic injuries can cause right knee effusion.
Arthropathies
Various joint diseases, some of which cause knee effusions.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the effusion traumatic?
When to use each related code
| Description |
|---|
| Right Knee Effusion |
| Right Knee Osteoarthritis |
| Right Knee Meniscus Tear |
Coding unspecified effusion (M25.461) without documenting the cause can lead to claim denials and lower reimbursement.
Incorrectly coding traumatic (S18.101A) vs. non-traumatic effusion impacts severity and reimbursement. Clear documentation is crucial.
Failing to document laterality (right knee) with effusion code (M25.461) causes coding errors and claim rejections.
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].