August 11, 2022 | Net Health

8 min read

The Ultimate Guide to ICD-10 Coding for Total Knee Replacements

Total knee replacement (TKR) surgery is one of the most common major orthopedic procedures performed today. And, as part of the patient care team, skilled and talented coders and billers use ICD-10 codes to capture these total knee replacement patients’ journeys.

More than 600,000 total knee replacement surgeries are performed each year in the U.S., a number that is expected to increase to 1,272,000 by 20251. As these numbers grow, physical therapy continues to be an integral part of patient journeys and health services as a whole.

Experts weighed in: Is Physical Therapy After Total Hip Replacement Necessary? Read this comprehensive blog and learn more.

From the time patients identify knee injury pain and mobility issues to seeking non-surgical treatment, diagnosis insight, as well as pre- and post-op knee replacement treatment, ICD-10 codes track their care. Joint pain is a common symptom that leads to the consideration of total knee replacement as a solution to restore mobility and relieve discomfort.

They allow both small and large physical therapy clinics to actively follow patients from knee pain, through surgery, and into rehab on the road to optimal function and mobility.

In addition, billers and coders endeavor to optimize claim reimbursements with ICD-10 and strive to utilize tools that encourage positive patient engagement in our physical therapy clinics. At the same time, efficient and successful ICD-10 tools create opportunities for excellent staff retention.

Read more about ICD 10 Z Codes to Identify Determinants of Health

Decode the Total Knee Replacement Patient Journey with ICD-10

Most working in physical therapy with knee replacement patients are familiar with the ICD-10 Z codes. The total knee replacement aftercare billable specific ICD-10 code often used for reimbursement purposes is Z47.1. But, if the patient has ongoing issues with their knee replacement, even better Z codes are available.

For the presence of artificial knee joint with chronic pain, revision, or prosthesis failure, as examples, use Z96.65 codes. These codes allow for further specificity for right, left, bilateral, and unspecified artificial knee joints, including differentiation based on the type of encounter, such as the initial encounter. They also cover injuries to the anterior cruciate ligament and posterior cruciate ligament, specifying whether the injury affects the left knee, right knee, or is unspecified. In scenarios where the affected knee is not documented, the term ‘unspecified knee’ is used to ensure accurate coding.

It is also important to consider treatment-specific ICD-10 codes to complement the Z codes noted above. Therapists need to assess the patient and determine what related impairments are present that need to be addressed in the plan of care.

Commonly used ICD-10 codes for total knee replacement treatment might include those for pain, effusion/swelling, stiffness/loss of motion, and gait abnormalities.  

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While including treatment diagnosis codes further supports the medical necessity of therapy services, you must check payer-specific guidelines and local coverage articles when choosing your diagnosis codes.

The Well-Coded ICD-10 Patient Journey Encourages Positive Patient Engagement

We know patient care for knee joint pain does not begin or end with knee replacement surgery. To complicate physical therapy billing matters, one experiencing knee joint chronic pain in the left knee, for example, requiring bilateral total knee arthroplasty might be replaced, while the right knee has ongoing osteoporosis and is awaiting surgery.

To ensure specific and accurate total knee replacement ICD-10 codes for physical therapy, we consider the etiology behind the knee pain such as:

  • osteoarthritis
  • post-traumatic degenerative joint disease
  • rheumatoid arthritis
  • bilateral secondary osteoarthritis, or
  • unilateral secondary osteoarthritis.

These specific conditions, including bilateral secondary osteoarthritis of the knee under the category of M17.4 and unilateral secondary osteoarthritis, will cause chronic knee pain and can lead to the need for a knee replacement. Along with a specialized EHR, an accurate ICD-10 physical therapy evaluation code with high-level specificity illustrate the patients’ unique history, including factors influencing health status and contact with health services.

This comprehensive approach highlights how various elements impact an individual’s health status and their interaction with healthcare services, playing a crucial role in the patient’s journey and treatment outcomes. This documentation creates action items to further assist patients in completing their care plans. With improved patient outcomes, the result is delighted therapists, satisfied patients, and a thriving business.

Streamline Revenue from Total Knee Replacements with ICD-10 Coding Automation

Effective ICD-10 coding tools help successfully process knee replacement physical therapy billing. A growth industry, the global joint replacement market size was valued at $17.1 billion in 20202, with the largest revenue share of 46% in knee joint replacement.

Due to an aging population and the prevalence of osteoporosis and rheumatoid arthritis, the global joint replacement market size is expected to grow by a (CAGR) of 3.4% from 2021 to 2028. Notably, chronic pain after TKR is experienced by approximately 20% of patients3. This may negatively impact the patient’s quality of life, function and mobility.

Physical therapy following total knee replacement surgery is an identified recommended treatment protocol for improving post-surgical outcomes.4  Using a highly customizable and tailored outpatient physical therapy EHR and billing software can streamline billing processes and improve reimbursement. Automated ICD-10 coding and billing success improves office morale and increases staff retention.

Net Health’s TherapyExpert for Clinics EHR is the solution that makes ICD-10 coding and other billing/compliance tasks simpler. It does so through automation and by providing the billing team access to a fully customizable, configurable coding and compliance engine. Front-end, back-end, billers, and coders are thrilled with the job scheduling, accounting, and automated optimal coding.

It is all the outpatient therapy EMR and billing software you need in one package to maximize ICD-10 diagnosis coding, improve reimbursement, increase patient engagement and provide outstanding staff with excellent tools.

Still want to learn more about this topic? Keep reading to learn more about the importance of ICD-10 codes in physical therapy, their benefits and challenges, and their role in clinical decision-making.

The Importance of ICD-10 Diagnosis Code in Physical Therapy

Standardization of Diagnoses

ICD-10 as a primary diagnosis code provides a standardized system that helps physical therapists classify and diagnose patients’ conditions accurately. It helps physical therapists ensure that they are using consistent language and terminology when communicating with other healthcare professionals, such as physicians and insurance companies. This uniformity is essential in fostering better interdisciplinary collaboration, facilitating accurate reporting of diagnoses, and promoting high-quality patient care.

Reimbursement and Billing

Accurate diagnosis and billing are critical for physical therapists to receive reimbursement for their services. ICD-10 codes are used by insurance companies to determine the type and extent of coverage for different healthcare services. By using the correct external cause ICD codes for a patient’s diagnosis, physical therapists can ensure that they are reimbursed accurately for their work, as well as ensuring that the patient receives the appropriate level of care.

Clinical Decision-Making

ICD-10 codes play a significant role in clinical decision-making for therapists. By using these codes to identify a patient’s specific condition, therapists can tailor their treatment plans to address the unique needs of each patient. This process ensures that patients receive the most effective and efficient care possible, ultimately improving patient outcomes.

Quality Improvement and Outcome Measurement

The use of the ICD-10 diagnosis code in physical therapy can help therapists track and measure the quality of their care. By analyzing data related to specific diagnoses and their associated treatments, physical therapists can identify trends, patterns, and areas for improvement. This information can then be used to refine treatment approaches, enhance the overall quality of care, and improve patient outcomes.

Research and Data Collection

External cause codes serves as a valuable tool for research and data collection in the field of physical therapy. By providing a consistent and standardized system for classifying diagnoses, researchers can analyze and compare data across studies, populations, and locations. This information is essential in identifying best practices, advancing knowledge in the field, and informing policy and practice changes.

More Benefits of ICD-10 Codes in Physical Therapy

Enhanced Patient Care

The use of ICD-10 codes in physical therapy allows therapists to provide more targeted and personalized treatment plans, which can lead to improved patient outcomes.

By utilizing these codes, therapists can ensure that patients receive the most appropriate and effective care.

Improved Interprofessional Communication

ICD-10 codes provide a common language for healthcare professionals, promoting better communication and collaboration among varying disciplines.

This improved communication can lead to more comprehensive and coordinated care for patients, enhancing the overall quality of healthcare services.

Accurate Reimbursement and Billing for Total Knee Replacement

Accurate reimbursement and billing are obvious benefits of using ICD-10 codes in physical therapy.

By employing the correct diagnostic codes, therapists can ensure that they receive appropriate compensation for their services and avoid potential disputes with insurance providers.

This accuracy in billing not only protects the financial health of their practice but also safeguards patients from unexpected out-of-pocket expenses.

Conclusions on Total Knee Replacement ICD-10 Coding

Overall, the precise use of ICD-10 codes for billing and reimbursement purposes strengthens the financial stability of physical therapy practices and enhances the patient experience.

You can check out Net Health’s resource hub to learn more about ICD-10, total knee replacement and how to help patients with chronic pain in the right knee or left knee (unspecified knee), as well as helping patients repair the musculoskeletal system, CPT codes and a slew of other tips and topics written just for rehab therapists.

The Journal of Rheumatology, Rates of Total Joint Replacement in the United States: Future Projections to 2020–2040 Using the National Inpatient Sample, April 2019
2 Grand View Research, Joint Replacement Market Size, Share & Trends Analysis Report By Product (Knees, Hips, Extremities), By Fixation Type, By End-use (Hospitals, Orthopedic Clinics), By Procedure, By Region, And Segment Forecasts, 2021 – 2028, July 2022
EFFORT Open Revies, Chronic pain after total knee arthroplasty, Aug 16, 2018
PTJ: Physical Therapy & Rehabilitation Journal, Physical Therapist Management of Total Knee Arthroplasty, June 16, 2020

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