Find information on Right Knee Strain diagnosis, including relevant clinical documentation, medical coding (ICD-10, SNOMED CT), symptoms, treatment, and prognosis. Learn about right knee strain grading, physical exam findings, and common differential diagnoses for accurate healthcare record keeping and billing. Explore resources for knee pain, muscle strain, ligament sprain, and soft tissue injuries of the right knee. This comprehensive guide helps healthcare professionals ensure proper documentation and coding for Right Knee Strain.
Also known as
Sprain and strain of knee and leg
Covers sprains and strains of the knee and leg.
Pain in knee
Specifies pain localized to the knee joint.
Falls
Encompasses various types of falls, a common cause of knee strains.
Activity codes
Can specify the activity causing the knee strain.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is there a tear of the right knee ligament?
Yes
Code a right knee sprain with a specific 7th character for the current encounter and the appropriate ICD-10-CM code for the tear (e.g., S83.511A, S83.512A with a ligament tear code).
No
Is the right knee strain specified as chronic?
When to use each related code
Description |
---|
Right Knee Strain |
Right Knee Sprain |
Right Knee Internal Derangement |
Coding with unspecified strain (S86.9) without documenting specific location or laterality increases claim denial risk and reduces reimbursement.
Lack of documentation specifying laterality (right) or degree (mild, moderate, severe) may lead to coding errors and compliance issues.
Missing documentation of major comorbidities/complications (MCC/CC) with right knee strain impacts accurate DRG assignment and appropriate reimbursement.
Patient presents with complaints of right knee pain consistent with a right knee strain. Onset of pain occurred [Date of onset] while [Mechanism of injury - e.g., running, twisting, playing sports]. Patient denies any popping or clicking sounds at the time of injury. Pain is localized to the [Location of pain - e.g., medial aspect, lateral aspect, posterior knee] and described as [Character of pain - e.g., sharp, dull, aching]. Patient reports [Severity of pain - e.g., mild, moderate, severe] pain, aggravated by [Aggravating factors - e.g., weight-bearing, bending, straightening] and alleviated by [Alleviating factors - e.g., rest, ice, elevation]. Physical examination reveals [Objective findings - e.g., tenderness to palpation, mild swelling, full range of motion with pain at end range, negative McMurray test]. No signs of effusion or instability are noted. Diagnosis of right knee strain is made based on clinical presentation and physical examination findings. Differential diagnoses considered include meniscus tear, ligament sprain, and patellofemoral pain syndrome. Treatment plan includes RICE therapy (rest, ice, compression, elevation), NSAIDs for pain management, and physical therapy for strengthening and range of motion exercises. Patient advised to avoid strenuous activities and weight-bearing as tolerated. Follow-up appointment scheduled in [Duration - e.g., one week, two weeks] to assess progress and adjust treatment plan as needed. ICD-10 code S13.411A, Right knee strain.