ICD-10 Coding for De Quervain's Synovitis(M65.4, M65.41, M65.42, M65.49)
Complete ICD-10-CM coding and documentation guide for De Quervain's Synovitis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to De Quervain's Synovitis
M65.4-M65.49Primary Range
Radial styloid tenosynovitis [de Quervain]
This range includes all codes related to De Quervain's synovitis, specifying laterality.
Occupational exposure to other risk factors
Used for cases where De Quervain's synovitis is related to occupational exposure.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| M65.4 | Radial styloid tenosynovitis [de Quervain] | Use when De Quervain's synovitis is confirmed but laterality is unspecified. |
|
| M65.41 | Radial styloid tenosynovitis, right wrist | Use when De Quervain's synovitis is confirmed in the right wrist. |
|
| M65.42 | Radial styloid tenosynovitis, left wrist | Use when De Quervain's synovitis is confirmed in the left wrist. |
|
| M65.49 | Radial styloid tenosynovitis, unspecified wrist | Use when laterality is not documented. |
|
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 De Quervain's synovitis
Essential facts and insights about De Quervain's Synovitis
Primary ICD-10-CM Codes for dequervains synovitis
Decision Criteria
clinical Criteria
- Presence of pain and swelling over the radial styloid.
documentation Criteria
- Documented laterality and occupational exposure if applicable.
Applicable To
- De Quervain's disease
- De Quervain's syndrome
Clinical Validation Requirements
- Positive Finkelstein test
- Ultrasound showing thickened tendon sheath
Code-Specific Risks
- Risk of unspecified laterality leading to incorrect billing.
Coding Notes
- Ensure laterality is documented to avoid unspecified coding.
M65.41 - Radial styloid tenosynovitis, right wrist
Use when De Quervain's synovitis is confirmed in the right wrist.
Applicable To
- Right wrist De Quervain's
Clinical Validation Requirements
- Positive Finkelstein test on right wrist
- Ultrasound confirmation
Coding Notes
Ensure right wrist involvement is clearly documented.
M65.42 - Radial styloid tenosynovitis, left wrist
Use when De Quervain's synovitis is confirmed in the left wrist.
Applicable To
- Left wrist De Quervain's
Clinical Validation Requirements
- Positive Finkelstein test on left wrist
- Ultrasound confirmation
Coding Notes
Ensure left wrist involvement is clearly documented.
M65.49 - Radial styloid tenosynovitis, unspecified wrist
Use when laterality is not documented.
Clinical Validation Requirements
- General symptoms without specific laterality.
Coding Notes
Avoid using unless absolutely necessary.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Occupational exposure to other risk factors
Z57.8Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting De Quervain's Synovitis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M65.4.
Impact
Clinical: Leads to inaccurate patient records., Regulatory: Non-compliance with ICD-10 guidelines., Financial: Potential for claim denials.
Mitigation Strategy
Always verify laterality before coding., Use checklists to ensure all documentation elements are present.
Impact
Reimbursement: May lead to denied claims or reduced reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Decreases accuracy of patient records.
Mitigation Strategy
Ensure laterality is documented as right, left, or bilateral.
Impact
Failure to document laterality can lead to audits.
Mitigation Strategy
Implement mandatory fields for laterality in EHR systems.
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 De Quervain's Synovitis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for De Quervain's Synovitis
Use these documentation templates to ensure complete and accurate documentation for De Quervain's Synovitis. These templates include all required elements for proper coding and billing.
Occupational Medicine Evaluation
Specialty: Occupational MedicineRequired Elements
- Subjective complaints
- Objective findings
- Assessment
- Plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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