Primary Care Coding Alert

Question: A patient has early post traumatic arthritis and early degenerative joint disease of the knee. She also has a history of proximal tibia fracture. What is the correct arthritis diagnosis code?

Answer: Your best choices are 716.16 (Traumatic arthropathy; lower leg) to describe the patient's current condition and 905.4 (Late effect of fracture of lower extremities) to explain the underlying cause.

Avoid: Another option at first glance is V15.51 (Injury; traumatic fracture). Don't report it, however, because V15.51 is a status code to note the patient is at higher risk for a refracture. The combination of 716.16 and 905.4 gives a clearer picture of the situation.