Revenue Cycle Insider

Question: I have a medical record that lists the diagnosis as “effusion of the left ankle.” What is ankle effusion and how do I report the condition?

Michigan Subscriber

Answer: Ankle effusion is a type of joint effusion that affects the ankle. Joint effusion occurs when there is an increase in intra-articular fluid within a joint or the tissues surrounding the joint. Typically, joint effusion is caused by an injury or trauma, but inflammation, blood disorders, or infections can also spur the condition’s onset.

Effusion symptoms can include:

• Pain
• Swelling
• Warmth
• Stiffness
• Restricted movement

You’ll assign one of the codes listed in the M25.47- (Effusion, ankle and foot) subcategory to report the diagnosis. The subcategory has three codes listed, each requiring a 6^th character. The 6^th character indicates on which side of the body the condition is occurring. Use M25.472 (Effusion, left ankle) for joint effusion in the left ankle.

Mike Shaughnessy, BA, CPC, Development Editor, AAPC