ICD-10 Coding for Right Knee Strain(S76.011)
Complete ICD-10-CM coding and documentation guide for Right Knee Strain. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Right Knee Strain
S76.0-S76.9Primary Range
Injury of muscle, fascia and tendon at hip and thigh level
This range includes codes for strains and injuries to the muscles and tendons of the hip and thigh, including the right knee.
Pain in joint
This range is used for chronic or non-traumatic joint pain, which may be relevant if the strain is not acute.
Key Information: ICD-10 code for right knee strain
Essential facts and insights about Right Knee Strain
Primary ICD-10-CM Code for right knee strain
Decision Criteria
clinical Criteria
- MRI confirms muscle/tendon strain
documentation Criteria
- Documented mechanism of injury and physical exam findings
Applicable To
- Acute strain of quadriceps
- Patellar tendon strain
Clinical Validation Requirements
- MRI showing partial/full-thickness tear of quadriceps/patellar tendon
- Tenderness at suprapatellar region
- Weakness on manual muscle testing (knee extension)
Code-Specific Risks
- Incorrectly coding chronic pain as acute strain
- Omitting laterality or episode of care
Coding Notes
- Ensure documentation specifies the mechanism of injury and confirms muscle/tendon involvement.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Pain in right knee
M25.561Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Sprain of ligaments of knee
S83.5-Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Right Knee Strain to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S76.011.
Impact
Clinical: Inadequate clinical information for treatment planning., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials due to insufficient documentation.
Mitigation Strategy
Use detailed templates, Educate providers on documentation standards
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with ICD-10 coding guidelines., Data Quality: Inaccurate clinical data affecting patient records.
Mitigation Strategy
Use M25.561 for chronic pain without recent trauma.
Impact
Coding chronic knee pain as an acute strain can trigger audits.
Mitigation Strategy
Ensure accurate differentiation between acute and chronic conditions.
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 Strain, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Right Knee Strain
Use these documentation templates to ensure complete and accurate documentation for Right Knee Strain. These templates include all required elements for proper coding and billing.
Acute Right Knee Strain in Orthopedic Clinic
Specialty: OrthopedicsRequired Elements
- Subjective: Onset and mechanism of injury
- Objective: Physical exam findings
- Assessment: Diagnosis with ICD-10 code
- Plan: Treatment and follow-up
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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