2. Coding for ACL Sprain
Patient is a 16-year-old male. During a high school soccer game last week,
he suffered a right ACL sprain when his knee contacted an opposing
player’s leg. He came straight to PT without seeing a physician first.
• Patient’s condition:
- Presents with pain, edema, and instability in his right knee
- Uses crutches for ambulation
- Has pain with walking
3. Answer!
Primary Codes:
• S83.511A Sprain of anterior
cruciate ligament or right knee
initial encounter
• W51.XXXA Accidental striking
against or bumped into by
another person
• Y92.322 Soccer field for place
of occurrence
• Y93.66 Activity, Soccer
- Additional Codes:
• R26.2 for difficulty in walking
or R26.89for other
abnormalities of gait and
mobility
• M25.561 for right knee pain
• M25.361 for the right knee
instability
• M25.461 for right knee
effusion
4. Left Knee Joint Replacement
Patient is a 74-year-old male who underwent a left total knee
replacement one week ago.
• Patient’s condition:
• complains of 6/10 pain in the left knee
• presents with left knee effusion and impaired range of motion
in left knee extension and flexion
• has pain with walking
• is WBAT (weight bearing as tolerated) using a walker
5. Answer!
Primary Codes:
R26.2 for difficulty in
walking or R26.89 for other
abnormalities of gait and
mobility
M25.562 for left knee pain
M25.462 for left knee
effusion
M25.662 for left knee
stiffness
M62.552 for muscle atrophy
left quads and hamstrings
- Additional Codes:
Z96.652 for presence of
left artificial knee joint
Z47.1 for aftercare
following joint
replacement surgery
6. Coding for Benign Proximal Vertigo
Patient is a 33-year-old female who presents to physical therapy
with a diagnosis of benign paroxysmal vertigo, right ear.
• Patient’s condition:
- Complains of dizziness and nausea
7. Answer!
• H81.11 for Benign Paroxysmal Vertigo, right ear
• R11.0 for nausea without vomiting
8. Coding for a Jack-O-Lantern Injury
Patient is a 34‐year-old female. While carving a pumpkin, she accidentally
lacerated the digital nerves at her palm as well as her flexor tendon
superficialis and profundus tendons on fingers two through four.
• Patient’s condition:
- Had surgery last week
- Presents with complaints of pain, swelling, and weakness of the right
wrist, hand, and fingers
- Has sensation of “pins and needles” in her hand and fingers
9. Answer!
• M79.641 pain in right hand
• M79.644 pain in right
fingers
• -M25.531 pain in right wrist
• -M25.431 for effusion of
right wrist
• -M25.441 for effusion of
right hand
• R20.2 paresthesia of skin
• M25.631 stiffness of right
wrist
• M25.641 stiffness of right
hand
• M62.531 and M62.541 for
muscle weakness right
forearm and hand
• S66.120D, S66.122D,
S66.124D for the lacerations
• W26.0XXD for contact with
knife
10. For a more detailed explanation of
each senario, and why/how the
codes were chosen
