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ICD-10 Coding for Baker's Cyst(M71.22, M71.21)

Complete ICD-10-CM coding and documentation guide for Baker's Cyst. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

Popliteal CystSynovial Cyst of the Kneesynovial cyst popliteal space

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Related ICD-10 Code Ranges

Complete code families applicable to Baker's Cyst

M71.2Primary Range

Synovial cyst of popliteal space

This range includes codes specifically for Baker's cysts, which are synovial cysts located in the popliteal space.

M17

Osteoarthritis of knee

Relevant when Baker's cyst is secondary to osteoarthritis.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
M71.22Synovial cyst of popliteal space, left kneeUse when a Baker's cyst is confirmed in the left knee via imaging.
  • Confirmed via imaging (ultrasound/MRI)
  • Localized swelling/pain in popliteal fossa
M71.21Synovial cyst of popliteal space, right kneeUse when a Baker's cyst is confirmed in the right knee via imaging.
  • Confirmed via imaging (ultrasound/MRI)
  • Localized swelling/pain in popliteal fossa

Clinical Decision Support

Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.

Key Information: ICD-10 code for Baker's cyst

Essential facts and insights about Baker's Cyst

The ICD-10 code for a Baker's cyst in the left knee is M71.22, and for the right knee, it is M71.21.

Primary ICD-10-CM Codes for bakers cyst

M71.22
Synovial cyst of popliteal space, left knee
Billable Code

Decision Criteria

clinical Criteria

  • Presence of a cyst in the popliteal space confirmed by imaging.

coding Criteria

  • Use M71.22 for left knee Baker's cyst.

Applicable To

  • Baker's cyst of the left knee

Excludes

  • Ganglion cyst (M67.4)
  • Synovial cyst not in popliteal space (M66.2-)

Clinical Validation Requirements

  • Confirmed via imaging (ultrasound/MRI)
  • Localized swelling/pain in popliteal fossa

Code-Specific Risks

  • Confusing with ganglion cyst codes
  • Missing laterality

Coding Notes

  • Ensure imaging confirmation and specify laterality.
View Full Code Details

Ancillary Codes

Additional codes that should be used in conjunction with the main diagnosis codes when applicable.

Bilateral primary osteoarthritis of knee

M17.0
Use if the cyst is secondary to osteoarthritis.

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Ganglion cyst

M67.4
Baker's cyst is a synovial cyst, not a ganglion cyst.

Synovial cyst not in popliteal space

M66.2-
Baker's cyst specifically occurs in the popliteal space.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting Baker's Cyst to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M71.22.

Impact

Clinical: May lead to incorrect treatment planning., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials due to incomplete documentation.

Mitigation Strategy

Always document whether the cyst is on the left or right knee., Use templates that prompt for laterality.

Impact

Reimbursement: Incorrect coding may lead to claim denials., Compliance: Using incorrect codes can result in non-compliance with coding guidelines., Data Quality: Misclassification affects data accuracy and quality.

Mitigation Strategy

Use 20610 for aspiration of Baker's cyst as it is a synovial cyst.

Impact

Using 20612 instead of 20610 for Baker's cyst aspiration.

Mitigation Strategy

Ensure documentation specifies the cyst type and location.

Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.

Frequently Asked Questions

Common questions about ICD-10 coding for Baker's Cyst, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for Baker's Cyst

Use these documentation templates to ensure complete and accurate documentation for Baker's Cyst. These templates include all required elements for proper coding and billing.

Orthopedic Evaluation of Baker's Cyst

Specialty: Orthopedics

Required Elements

  • Patient history
  • Physical examination findings
  • Imaging results
  • Diagnosis
  • Treatment plan

Example Documentation

**Subjective**: Pt reports posterior knee pain worsening with flexion. No trauma. **Objective**: TTP popliteal fossa, + palpable mass. ROM 0-110° (limited by pain). **Imaging**: MRI shows 2.5 cm synovial cyst communicating with knee joint, medial meniscal tear. **Assessment**: M71.22 (Baker’s cyst, left knee); S83.232A (Bucket-handle tear, medial meniscus). **Plan**: Ultrasound-guided aspiration (CPT 20610 + 76942).

Examples: Poor vs. Good Documentation

Poor Documentation Example
Patient has Baker’s cyst.
Good Documentation Example
3 cm fluid-filled cyst in left popliteal fossa on ultrasound, associated with Grade 3 medial meniscal tear. Patient reports locking and reduced ROM.
Explanation
The good example provides specific details about the cyst's size, location, associated conditions, and symptoms, which are necessary for accurate coding and treatment planning.

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