ICD-10 Coding for Right Knee Instability(M25.361, M23.51, S83.51xA)
Complete ICD-10-CM coding and documentation guide for Right Knee Instability. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Right Knee Instability
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| M25.361 | Other instability, right knee | Use for acute or subacute instability from recent injury or non-chronic causes. |
|
| M23.51 | Chronic instability, right knee | Use for chronic instability from old ligament tears or recurrent dislocations. |
|
| S83.51xA | Sprain of anterior cruciate ligament of right knee, initial encounter | Use for acute ACL tears causing knee instability. |
|
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 right knee instability
Essential facts and insights about Right Knee Instability
Primary ICD-10-CM Codes for right knee instability
Decision Criteria
clinical Criteria
- Objective instability findings on physical exam
documentation Criteria
- Documentation of recent injury leading to instability
Applicable To
- Acute instability due to recent injury
Excludes
- Chronic instability (M23.51)
Clinical Validation Requirements
- Objective instability on exam (e.g., positive anterior drawer test)
- Documentation of recent injury
Code-Specific Risks
- Risk of using unspecified laterality code (M25.369)
Coding Notes
- Ensure documentation specifies right knee and includes objective test results.
M23.51 - Chronic instability, right knee
Use for chronic instability from old ligament tears or recurrent dislocations.
Applicable To
- Instability from old ligament tears
Excludes
- Acute instability (M25.361)
Clinical Validation Requirements
- History of prior injury or surgery
- Persistent instability on exam
Coding Notes
Ensure documentation includes history of chronic instability.
S83.51xA - Sprain of anterior cruciate ligament of right knee, initial encounter
Use for acute ACL tears causing knee instability.
Applicable To
- Acute ACL tear causing instability
Clinical Validation Requirements
- MRI-confirmed ACL tear
- Instability findings on physical exam
Coding Notes
Ensure MRI findings are documented to support ACL tear diagnosis.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Right Knee Instability to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M25.361.
Impact
Clinical: Inadequate information for treatment planning., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials.
Mitigation Strategy
Include specific test results and history.
Impact
Reimbursement: Claims may be denied or delayed., Compliance: Non-compliance with ICD-10 specificity requirements., Data Quality: Inaccurate data for clinical and research purposes.
Mitigation Strategy
Specify 'right' in documentation and use M25.361.
Impact
Reimbursement: Improper sequencing can lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Incomplete clinical picture.
Mitigation Strategy
Sequence S83.511A first for post-ACL tear instability.
Impact
Lack of documented objective tests can lead to audit failures.
Mitigation Strategy
Ensure all objective tests are documented with results.
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 Right Knee Instability, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Right Knee Instability
Use these documentation templates to ensure complete and accurate documentation for Right Knee Instability. These templates include all required elements for proper coding and billing.
Orthopedic Progress Note
Specialty: OrthopedicsRequired Elements
- Subjective findings
- Objective test results
- Assessment and plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Right Knee Instability? Ask your questions below.