ICD Code M65.961

ICD code M65.961 is used to identify a medical condition characterized by unspecified synovitis and tenosynovitis affecting the right lower leg. Synovitis refers to the inflammation of the synovial membrane, which lines joints and tendons, while tenosynovitis involves inflammation of the sheath surrounding a tendon. This code is utilized when the specific cause or type of synovitis and tenosynovitis in the right lower leg is not detailed, allowing healthcare providers to document and communicate the condition for treatment and billing purposes.

When to use the ICD code for unspecified synovitis and tenosynovitis of the right lower leg:

1. Presence of Joint Swelling: Noticeable swelling in the right lower leg joint area.

2. Pain in the Affected Area: Patient reports pain localized to the right lower leg, particularly around the joints or tendons.

3. Limited Range of Motion: Difficulty or discomfort when attempting to move the right lower leg or foot.

4. Tenderness on Palpation: Tenderness or sensitivity when the right lower leg is touched or examined.

5. Warmth or Redness: Observable warmth or redness in the skin overlying the affected area of the right lower leg.

6. History of Joint or Tendon Issues: Previous history of joint or tendon problems in the right lower leg, including prior injuries or inflammatory conditions.

7. Absence of Specific Diagnosis: No definitive diagnosis established that explains the symptoms, leading to the classification as unspecified synovitis and tenosynovitis.

For the ICD code M65.961, which pertains to unspecified synovitis and tenosynovitis of the 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 joint, subacromial bursa); without ultrasound guidance.

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

3. 27370 - Injection of a therapeutic substance into the knee joint.

4. 29240 - Strapping of the knee.

5. 29540 - Strapping; ankle and/or foot.

6. 97035 - Application of a modality to one or more areas; ultrasound, each 15 minutes.

7. 97110 - Therapeutic exercises to develop strength and endurance, range of motion, and flexibility (each 15 minutes).

These CPT codes are commonly used for procedures and treatments that may be relevant for addressing conditions associated with synovitis and tenosynovitis in the lower leg. It is important for healthcare providers to select the appropriate CPT code based on the specific treatment rendered and the clinical scenario.

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