Knee is one of the biggest joint in body which joints thigh bone (femur) and lower leg joint (tibia). The knee cap is called patella. Tendons (flexible connective tissue) and ligaments (inelastic collagen tissue) help joining these bones and make the knee joint.
There may be need of radiological tests (X-ray, CT, MRI, ultrasound) or arthrocentesis (lab analysis of knee joint fluid) for further evaluation to check for infections or injury to tendon or ligament.
Knee pain can be mild, moderate or severe. The reasons for pain can vary such as injury, overuse, infection and inflammation. Sometimes there may be swelling and redness depends on the cause. We need to visit doctor as per the severity and as per how long the pain lasts.
Knee pain is a symptom; hence follow ICD coding guideline of not coding signs and symptoms when there is a definitive diagnosis made.
Review the entire medical record thoroughly especially physical examination to determine the correct anatomical site of pain. Do not code unspecified knee pain if there is any site specification mentioned in the record.
Hoffa’s syndrome is not coded as it is mentioned as “possible”.