ICD Code M65.861

ICD code M65.861 is used to classify a medical diagnosis of "Other synovitis and tenosynovitis, right lower leg." This code indicates that the patient is experiencing inflammation of the synovium, which is the lining of a joint, or the tendon sheath in the right lower leg. This condition can cause pain, swelling, and difficulty in movement, and it may result from various causes such as overuse, injury, or underlying inflammatory diseases. Proper documentation of this ICD code is crucial for healthcare providers to ensure accurate billing and effective communication with insurance companies regarding the patient's condition and treatment plan.

When to use the ICD code M65861 for Other synovitis and tenosynovitis, right lower leg, consider the following diagnostic criteria and symptoms:

1. Localized Swelling: Presence of swelling in the right lower leg, particularly around joints or tendons.

2. Pain: Patient reports pain in the right lower leg, which may be exacerbated by movement or pressure.

3. Limited Range of Motion: Difficulty or discomfort when attempting to move the affected joints or tendons in the right lower leg.

4. Warmth and Redness: Observable warmth or redness in the area of the right lower leg, indicating inflammation.

5. Tenderness: Tenderness upon palpation of the affected area in the right lower leg.

6. History of Injury: Recent history of trauma or overuse that may have contributed to the development of synovitis or tenosynovitis.

7. Chronic Conditions: Presence of underlying chronic conditions such as rheumatoid arthritis or gout that may predispose the patient to synovitis or tenosynovitis.

8. Imaging Findings: Radiological evidence (e.g., MRI or ultrasound) indicating inflammation of the synovial membrane or tendons in the right lower leg.

9. Duration of Symptoms: Symptoms persisting for a duration that suggests a pathological process rather than a transient condition.

10. Response to Treatment: Evaluation of the patient's response to conservative treatments, such as rest, ice, compression, and elevation (RICE), which may indicate the severity of the condition.

These criteria should be assessed to determine the appropriateness of using the specified ICD code for documentation and billing purposes.

For the ICD code M65.861, which pertains to "Other synovitis and tenosynovitis, right lower leg," the relevant CPT codes that may be applicable for treatment include:

1. 20610 - Arthrocentesis, aspiration, and/or injection into a major joint or bursa (e.g., knee, hip, shoulder joint); without ultrasound guidance.

2. 20611 - Arthrocentesis, aspiration, and/or injection into a major joint or bursa (e.g., knee, hip, shoulder joint); with ultrasound guidance, with permanent recording and reporting.

3. 27370 - Injection of contrast for knee arthrography.

4. 27600 - Tenotomy, percutaneous, Achilles tendon (separate procedure); local anesthesia.

5. 27605 - Tenotomy, percutaneous, Achilles tendon (separate procedure); general anesthesia.

6. 27650 - Repair, primary, open or percutaneous, ruptured Achilles tendon.

7. 29888 - Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction.

These CPT codes are examples of procedures that might be performed to address conditions associated with synovitis and tenosynovitis in the right lower leg. It's important for healthcare providers to select the appropriate CPT code based on the specific procedure performed and the clinical scenario. Always ensure coding accuracy by consulting the latest CPT coding guidelines and payer-specific policies.

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