Podiatry Coding & Billing Alert

Question: The podiatrist documented that the patient has effusion in her right ankle. What ICD-10 code should I report for this condition?

Alaska Subscriber

Answer: For joint effusion in the right ankle, you should report M25.471 (Effusion, right ankle)

Your other choices for effusion of the ankle include the following codes:

• M25.472 (Effusion, left ankle)
• M25.473 (Effusion, unspecified ankle).

On the other hand, if the patient suffers from effusion of the foot, you would look to the following codes:

• M25.474 (Effusion, right foot)
• M25.475 (Effusion, left foot)
• M25.476 (Effusion, unspecified foot).

Joint effusion defined: Joint effusion (not to be confused with joint fusion) is the painful increase of intra-articular fluid within the joint or in the tissues that surround the joint. This condition occurs because of trauma, inflammation, hematologic conditions, or infection.

Symptoms: Effusion may result in pain, swelling, warmth, stiffness, and restricted movement of the joint.

Treatment options: Providers diagnose joint effusion based upon the patient’s history, including any trauma or disease; a physical exam; and imaging techniques like X rays.

Depending upon the underlying cause, treatment may include administering medications such as nonsteroidal anti-inflammatory drugs, corticosteroids, antirheumatics, and antibiotics; the application of moist heat and ice; or joint aspiration.