What CPT codes are used for knee evaluations?

E/M codes 99202-99215 based on MDM complexity. Knee arthroscopy uses 29870-29889 depending on procedure (29881 meniscectomy, 29888 ACL reconstruction). Injections use 20610 (large joint) with J-codes for medication. X-rays use 73560-73564. MRI uses 73721-73723. For workers' comp, document mechanism of injury, work-relatedness, and functional limitations affecting job duties.

What documentation supports medical necessity for knee MRI?

Document: clinical findings suggesting internal derangement (positive McMurray, Lachman, joint line tenderness), failure of conservative treatment (duration specified), functional limitations, and how MRI will change management. Include mechanism of injury, symptoms (locking, giving way), and physical exam findings. Medicare requires documented treatment plan change based on results.

How should ligament stability testing be documented?

Document specific tests with findings: Lachman (endpoint quality: firm/soft, translation grade 1-3), anterior drawer, pivot shift (negative/glide/clunk/gross), and comparison to contralateral knee. For MCL/LCL, document valgus/varus stress at 0° and 30° with grade I-III instability. Specific grading supports surgical planning and documents severity for coding.

What documentation is required for knee injection (20610)?

Document: indication for injection (osteoarthritis, effusion, inflammatory condition), consent obtained, site prepared, technique (approach), medication injected with volume and concentration, and patient response. Include specific diagnosis code supporting injection. For hyaluronic acid, document failure of conservative treatment and specific product used with J-code.

How do I document meniscal tear characteristics for surgical planning?

Document: meniscus involved (medial vs lateral), tear location (anterior horn, body, posterior horn), zone (red-red, red-white, white-white based on vascularity), tear pattern (horizontal, vertical, radial, complex, bucket handle), size, and displacement. Include McMurray results, joint line tenderness location, and mechanical symptoms. This determines repair vs meniscectomy approach.

Knee Evaluation Template - Orthopedics

Patient Information

Date: [Date]
Visit type: New / Follow-up / Post-injury / Post-operative
Side: Right / Left / Bilateral

Chief Complaint

[Primary knee symptom]
Duration: [Onset, timeline]
Current status: Improving / Stable / Worsening

History of Present Illness

Mechanism of injury: [If traumatic]

Date: [Date]
Activity: [Sport, fall, twist, direct blow]
Position of knee: [Flexion, extension, valgus, varus, rotation]
Felt/heard pop: Yes / No
Immediate swelling (<2 hours): Yes / No
Able to bear weight immediately: Yes / No
Able to continue activity: Yes / No

Onset: Acute traumatic / Gradual / Insidious
Symptoms:

Pain location: Medial / Lateral / Anterior / Posterior / Diffuse
Swelling: None / Intermittent / Constant
Mechanical symptoms:
Locking: Yes / No — [True lock vs catching]
Catching: Yes / No
Giving way: Yes / No — Frequency: [X]
Popping/clicking: Yes / No
Stiffness: Yes / No — AM / After sitting
Instability: Yes / No — With: [Cutting, pivoting, stairs, walking]

Functional Impact

Walking: Unlimited / [Distance limitation]
Stairs: Normal / Difficult ascending / Difficult descending / Requires rail
Running: Able / Unable
Cutting/pivoting: Able / Unable
Squatting: Able / Limited / Unable
Kneeling: Able / Painful / Unable
Sport participation: [Current level vs pre-injury]
Work limitations: None / Modified duty / Unable to work

Prior Knee History

Previous injuries (this knee): None / [ACL tear, meniscus tear, etc.]
Previous surgeries (this knee): None / [Procedure, date, surgeon]
Previous injections: None / [Type, date, response]
Physical therapy: [Prior treatment, response]
Contralateral knee: Normal / [Issues]

Risk Factors

Age: [X] years
Activity level: Sedentary / Recreational / Competitive athlete
Sport(s): [List]
BMI: [X]
Alignment: Neutral / Varus / Valgus (clinical observation)

Physical Examination

Standing:

Alignment: Neutral / Varus / Valgus
Gait: Normal / Antalgic / Thrust [varus/valgus]
Single leg stance: Stable / Unstable

Sitting:

Quadriceps tone: Symmetric / Atrophy [X cm above patella]
Patellar tracking: Normal / J-sign / Lateral tracking

Supine:

Inspection

Swelling: None / Mild / Moderate / Large

Location: Suprapatellar / Diffuse / [Localized]

Ecchymosis: None / [Location]
Scars: None / [Location, well-healed]
Skin: Intact / [Abnormality]

Palpation

Effusion: None / Small / Moderate / Large

Ballottement: Positive / Negative
Fluid wave: Positive / Negative

Tenderness:

Medial joint line: Yes / No
Lateral joint line: Yes / No
Medial femoral condyle: Yes / No
Lateral femoral condyle: Yes / No
Tibial plateau medial: Yes / No
Tibial plateau lateral: Yes / No
Patella: Yes / No — Facets: Medial / Lateral
Patellar tendon: Yes / No
Quadriceps tendon: Yes / No
Pes anserine: Yes / No
IT band: Yes / No
Fibular head: Yes / No
Popliteal fossa: Yes / No — Mass: Yes / No

Warmth: None / Present
Crepitus: None / Patellofemoral / Tibiofemoral

Range of Motion

Affected Contralateral
Extension: [X]° [X]°
Flexion: [X]° [X]°
Extension lag: None / [X]°

Ligament Examination

ACL Testing:

Lachman test: Negative / Positive
Endpoint: Firm / Soft
Translation: 1+ / 2+ / 3+ (mm: <5 / 5-10 / >10)
Anterior drawer: Negative / Positive — [Grade]
Pivot shift: Negative / Glide / Clunk / Gross

PCL Testing:

Posterior drawer: Negative / Positive — [Grade]
Quadriceps active test: Negative / Positive
Posterior sag sign: Negative / Positive

MCL Testing:

Valgus stress at 0°: Stable / Unstable [Grade I/II/III]
Valgus stress at 30°: Stable / Unstable [Grade I/II/III]

LCL/PLC Testing:

Varus stress at 0°: Stable / Unstable [Grade I/II/III]
Varus stress at 30°: Stable / Unstable [Grade I/II/III]
Dial test at 30°: Negative / Positive [External rotation asymmetry]
Dial test at 90°: Negative / Positive
Posterolateral drawer: Negative / Positive
Reverse pivot shift: Negative / Positive

Meniscal Testing

McMurray test:

Medial: Negative / Positive [Click, pain]
Lateral: Negative / Positive

Apley compression: Negative / Positive
Thessaly test: Negative / Positive [Medial / Lateral]
Joint line tenderness: Medial / Lateral / Neither / Both

Patellofemoral Examination

Patellar mobility: Normal / Hypermobile / Hypomobile
Patellar tilt: Neutral / Lateral / Medial
Apprehension test: Negative / Positive
Patellar grind (Clarke's): Negative / Positive
Q-angle: [X]° (normal <15° male, <20° female)

Strength (0-5)

Quadriceps: [X]/5
Hamstrings: [X]/5
Hip abductors: [X]/5

Neurovascular

Sensation: Intact / [Deficit location]
Pulses: DP [2+], PT [2+]
Compartments: Soft

Imaging Review

X-rays: [Date]

Standing AP: [Joint space, alignment, osteophytes]
Lateral: [Patella position, joint space]
Sunrise/Merchant: [Patellofemoral joint]
Long-leg alignment: [If obtained, mechanical axis]

MRI: [Date if available]

ACL: Intact / Partial tear / Complete tear
PCL: Intact / [Findings]
MCL: Intact / [Grade sprain]
LCL/PLC: Intact / [Findings]
Medial meniscus: Intact / [Tear type, location, zone]
Lateral meniscus: Intact / [Tear type, location, zone]
Articular cartilage: [Grade, location]
Bone: [Edema, fracture, lesion]
Other: [Effusion, Baker's cyst, loose bodies]

Assessment

1) [Primary diagnosis] — [Side]
[Classification/grade if applicable]
2) [Secondary diagnoses if present]

Plan

Conservative Management (if applicable)

1) Activity modification:

Weight-bearing: WBAT / Partial / Non-weight-bearing
Brace: [Type if indicated]
Crutches: [Duration if needed]

2) Physical therapy:

Focus: [ROM, strengthening, stability training]
Frequency: [X] times/week for [X] weeks

3) Medications:

[NSAIDs, analgesics as appropriate]

4) Injections (if indicated):

[Corticosteroid / Hyaluronic acid / PRP]
Location: Intra-articular / [Specific]

Surgical Management (if indicated)

Procedure: [Specific procedure]

ACL reconstruction: [Graft choice: BTB, hamstring, allograft, QT]
Meniscal: Repair vs partial meniscectomy
Cartilage: [Microfracture, OAT, ACI]
Arthroplasty: [TKA, UKA, PFA]

Timing: [Urgent, elective, after PT prehab]
Pre-operative: [Clearance, imaging, PT]

Follow-up

Return: [Timeframe]

Sooner if: Locking, increased swelling, giving way, fever

Patient Education

Diagnosis explanation, treatment rationale, activity restrictions, home exercises, ice/elevation for swelling, warning signs, expected recovery timeline.

Orthopedics — Knee Evaluation Template

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