Internal Medicine Coding Alert

Published on Mon Aug 27, 2007 PDF

Question: A new patient reports to the internist complaining of pain and swelling in her right knee. The physician diagnoses a meniscal tear during the course of a level three E/M service. How would you choose a diagnosis code for this encounter?


Oregon Subscriber

Answer: A meniscal tear is a common injury involving torn knee cartilage. There are two types of tears, and you'll need to go back and check the notes to see which type this patient suffered before coding this particular scenario.

Why? Your ICD-9 code choice depends on it.

On the report, you should see documentation that the patient has torn one of two knee menisci: the medial meniscus, located on the inside of the knee, and/or the lateral meniscus, located on the outside of the knee. These menisci serve as shock absorbers for the knee, but are easily torn as a result of wear-and-tear by athletes. Patients may also tear the menisci as a result of trauma, such as squatting or twisting the knee.

Option 1: If the patient suffered a medial meniscus tear, you should report 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a detailed history; a detailed examination; medical decision making of low complexity) for the E/M with 836.0 (Tear of medial cartilage or meniscus of knee, current) attached to represent the tear.

Option 2: If the patient suffered a lateral meniscus tear, you should report 99203 for the E/M with 836.1 (Tear of lateral cartilage or meniscus of knee, current).

Option 3: If the notes do not specify the injury as medial or lateral, you should report 99203 for the E/M with 836.2 (Other tear of cartilage or meniscus of knee, current) attached to represent the tear.

Check for degeneration: Meniscus tears can also be degenerative, especially in the older population. If the operative notes indicate that the patient has a degenerative meniscus tear, choose a code from the 717.0-717.5 (Internal derangement of knee). So if the physician diagnoses an old bucket handle tear in a patient's medial meniscus, you'd report 717.0 (Old bucket handle tear of medial meniscus).