Good Morning! I have a patient that had a CT done on his knee and I am trying find the appropriate ICD-10 code that is not unspecified. Any expert help would be appreciated!! Thanks a million! Kathy
CT LEFT KNEE WITHOUT CONTRAST
CLINICAL HISTORY: Left knee pain. Evaluate for suspected fracture.
COMPARISONS: Left knee radiograph 11/4/2016.
FINDINGS: There is a vertically oriented linear lucency between the anterior
tibial spines extending through the base of the medial tibial spine. The lucency
also traverses the posterior tibial metaphysis with intra-articular extension. A
small joint effusion is noted. There are postsurgical changes from placement of
an intramedullary nail in the distal left femur, incompletely evaluated. There
is severe tricompartmental degenerative joint space loss with subchondral cystic
erosive changes and anterior marginal osteophytes. Vascular calcifications of
the popliteal artery are noted.
IMPRESSION:
1. Nondisplaced fracture of the posterior tibial metaphysis with intra-articular
extension involving the tibial plateau and medial portion of the anterior tibial
spine.
CT LEFT KNEE WITHOUT CONTRAST
CLINICAL HISTORY: Left knee pain. Evaluate for suspected fracture.
COMPARISONS: Left knee radiograph 11/4/2016.
FINDINGS: There is a vertically oriented linear lucency between the anterior
tibial spines extending through the base of the medial tibial spine. The lucency
also traverses the posterior tibial metaphysis with intra-articular extension. A
small joint effusion is noted. There are postsurgical changes from placement of
an intramedullary nail in the distal left femur, incompletely evaluated. There
is severe tricompartmental degenerative joint space loss with subchondral cystic
erosive changes and anterior marginal osteophytes. Vascular calcifications of
the popliteal artery are noted.
IMPRESSION:
1. Nondisplaced fracture of the posterior tibial metaphysis with intra-articular
extension involving the tibial plateau and medial portion of the anterior tibial
spine.