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ICD-10 Coding for Tear of Medial Meniscus(S83.22XA, M23.21)

Complete ICD-10-CM coding and documentation guide for Tear of Medial Meniscus. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

Medial Meniscus TearMeniscal Tear

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Related ICD-10 Code Ranges

Complete code families applicable to Tear of Medial Meniscus

S83.2Primary Range

Tear of meniscus, current injury

This range covers acute traumatic tears of the meniscus, including specific types such as bucket handle tears.

M23.2

Derangement of meniscus due to old tear or injury

This range is used for chronic or degenerative meniscus tears, indicating long-term instability or degeneration.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
S83.22XATear of medial meniscus, current injury, initial encounterUse for acute traumatic tears of the medial meniscus during the initial encounter.
  • Documented traumatic onset
  • Positive McMurray’s test
  • MRI confirmation of tear
M23.21Derangement of medial meniscus due to old tear or injuryUse for chronic or degenerative tears of the medial meniscus.
  • Documented chronic instability
  • MRI showing degenerative changes

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 tear of medial meniscus

Essential facts and insights about Tear of Medial Meniscus

The ICD-10 code for an acute tear of the medial meniscus is S83.22XA, while chronic tears are coded as M23.21.

Primary ICD-10-CM Codes for tear of medial meniscus

S83.22XA
Tear of medial meniscus, current injury, initial encounter
Non-billable Code

Decision Criteria

clinical Criteria

  • Presence of acute trauma and positive imaging findings

documentation Criteria

  • Detailed mechanism of injury and imaging results

Applicable To

  • Acute traumatic tear of medial meniscus

Excludes

  • Chronic tear of medial meniscus (M23.21)

Clinical Validation Requirements

  • Documented traumatic onset
  • Positive McMurray’s test
  • MRI confirmation of tear

Code-Specific Risks

  • Misclassification as chronic if not properly documented

Coding Notes

  • Ensure documentation specifies the traumatic nature and laterality of the tear.
View Full Code Details

Ancillary Codes

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

Effusion, right knee

M25.561
Use to indicate associated effusion with the meniscus tear.

Differential Codes

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

Injury of muscle and tendon of thigh

S76.0
Use when there is a concurrent thigh muscle injury.

Osteoarthritis of knee, unspecified

M17.9
Use when osteoarthritis is the primary condition.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting Tear of Medial Meniscus to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S83.22XA.

Impact

Clinical: Leads to unspecified coding, affecting treatment plans., Regulatory: Non-compliance with coding standards., Financial: Potential for denied claims due to unspecified codes.

Mitigation Strategy

Always document right or left knee., Use templates to ensure completeness.

Impact

Reimbursement: Incorrect coding can lead to denied claims., Compliance: Misclassification affects compliance with coding standards., Data Quality: Impacts the accuracy of clinical data.

Mitigation Strategy

Verify the onset and nature of the tear before coding.

Impact

Using unspecified codes without justification can trigger audits.

Mitigation Strategy

Ensure complete documentation of injury specifics.

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 Tear of Medial Meniscus, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for Tear of Medial Meniscus

Use these documentation templates to ensure complete and accurate documentation for Tear of Medial Meniscus. These templates include all required elements for proper coding and billing.

Acute traumatic tear of medial meniscus

Specialty: Orthopedics

Required Elements

  • Mechanism of injury
  • Physical exam findings
  • Imaging results
  • Tear characteristics

Example Documentation

Patient presents with acute right knee pain after twisting injury. MRI shows a tear of the medial meniscus with 4mm extrusion.

Examples: Poor vs. Good Documentation

Poor Documentation Example
Patient has knee pain, MRI ordered.
Good Documentation Example
Patient presents with acute right knee pain after a twisting injury during soccer. MRI confirms a tear of the medial meniscus with 4mm extrusion.
Explanation
The good example provides specific details about the injury mechanism and imaging findings, supporting accurate coding.

Need help with ICD-10 coding for Tear of Medial Meniscus? Ask your questions below.

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