Knee effusions following arthroscopic surgery are quite common, in fact not having one is rare. As for the treatment by injection or aspiration & injection, the rationale for this should be clearly documented in the office note. The presence of an effusion is not necessarily an indication for the procedure. There should be some indication for the procedure, i.e. medical necessity. "Excessive postoperative pain" may be an indication if it is felt that the pain is due to the effusion, and that aspirating and/or injecting the joint would relieve the pain, i.e. pain management. There are reasons other than pain for doing this procedure postoperatively, but you brought it up in your query. But, the documentation has to be there to support it.
As for
diagnosis codes, I would recommend
M96.89: Other post-procedural complication &/or disorder of a musculoskeletal system/procedure, which has the Coding Note of
Use Additional Code to indicate the disorder. This is much more specific than
Z98.890 since it pertains to the musculoskeletal system. Then you can add
M25.46 _ for the
Knee Effusion, the disorder/complication. If this was done for
Pain Management, then you could add
G89.18 for
Other Acute Post-procedural Pain. This would be an adjunct code to help clarify the reason for the procedure.
As for the procedure/management codes, the
99024 would be correct since it is a postoperative follow up visit in the global period. There are several possible Modifiers that could be used, and I am not sure which is the best:
57: Decision for Surgery (Procedure) since the surgeon probably advised the injection and the patient consented;
58: Related procedure during the postoperative period by same physician; or
78: Unplanned return to procedure room for related procedure in the postoperative period, i.e. aspiration &/or injection of the knee joint. Finally there is
20610: Aspiration &/or Injection of the Knee Joint.
This is how I would approach this, but it would be interesting to see what others say. I hope this helps.
Respectfully submitted, Alan Pechacek, M.D.
icd10orthocoder.com
