Wiki Pain in "Knee" following Total Knee Arthroplasty

[KStaten]

Hello Everyone!

Coding Conundrum for the Day: Coding "Knee" Pain Following a Total Knee Replacement

Here's the scenario:
A patient returns to the office complaining of right "knee pain" after having had a total right knee replacement. Upon examination, the doctor cannot find anything that would link the pain to the internal implants and notes this lack of evidence in his/her report. The cause of the pain is left to be unknown.

My Overthinking Issues:
1) Since the doctor states that he/she cannot link the pain to the artificial knee implants, the code T84.84XA (Pain due to internal orthopedic prosthetic devices, implants and grafts, initial encounter) does not seem justified.

2) On the other hand, since the "knee," (which is defined as the joint formed by the proximal portion of the tibia, the distal end of the femur, and the patella) has been replaced and is now comprised of artificial components, the code M25.561 (Pain in right knee) does not seem justified, either.

3) Which leads me to the possibility of M79.661 (Pain in right lower leg). This seems more fitting... until someone argues that the knee is either part of the upper leg... or is considered neither the upper nor lower.

Thoughts? I'd love to hear your input!

Thank You in advance!
Kim

 

[Orthocoderpgu]

I would not assume that the "knee" itself is gone. The bones are basically "trimmed" so the implants can rest on what was the articular surfaces. For the tibia the meniscus both medially and laterally are removed and the implant is placed on top. If the knee pain cannot be contributed to the implant themselves, I would still use M25.561 or 562. In time you might see that the implants are coming loose or something like that, so then you could switch to T84.84XA.

 

[thomas7331]

I agree, the pain is still in the knee even if a joint replacement procedure has been performed. Code the symptom, knee pain M25.56-, and the joint replacement status Z96.65-, if a definitive diagnosis for cause of the pain has not been documented.

 

[KStaten]

Thank you both! I appreciate your help! As you've probably noticed, I tend to overthink.

Even with the thousands of codes we have available, however, I do no think that coding is an exact science. I've used "pain in the knee" following a replacement... but here is the nagging contradiction in my head:

Scenario:
1) The knee is replaced with total knee arthroplasty.
2) The "knee" becomes infected due to the internal prosthesis.
3) The knee prosthesis is removed and is replaced with an antibiotic spacer.
4) We are then directed to code....... Acquired Absence of the knee; Z89.521 /Z89.522.

So, in that scenario, according to the CPT codes, the "knee" is absent, and, thus, is no longer considered the "knee" once it has been altered / replaced with artificial parts.

I "kneed" to just stop overthinking. I'll try to limit my puns and digress.
As always, I appreciate and enjoy hearing everyone's input!

Thanks!
Kim

 

[thomas7331]

You're correct - coding is not an exact science, and this is because medicine is not either. Just keep in mind that your guiding principle should be to choose the codes, in accordance with the coding guidelines, that best represent what the provider has documented. So if the provider documents 'knee pain', but also documents the condition that warrants assignment of 'absence of knee', then so be it. There isn't an excludes note or other coding requirement here that prevents you from assigning both codes as long as both conditions are documented (and there is also no clinical reason to expect that a patient couldn't continue to report knee pain even after a knee prosthesis was removed). Some payers do make up nonsensical rules that will cause denials on contradictory situations like this, and you just have to deal with those situations when they come up. Bottom line is that the codes should support the documentation.

 

[tcraig]

I have a question in this same area, if I have a new patient that comes in with pain in knee. We do a 99203 and 73564, would i code the pain code of M25562 on the xray since it is a diagnostic xray and then the definitive code of osteo M1712 on the E/M or would i code the osteo on both and add pain as symptom. I have always coded pain to the xray since there is no definitive diagnosis, but i am being told I am wrong.

 

[Orthocoderpgu]

M17.12 is a definitive diagnosis. Knee pain is not. You use the same code on the X-rays as the E/M. If the physician has diagnosed osteoarthritis, that code would be used and the pain code would not be used since that is a symptom of osteoarthritis.