ICD-10-CM Code for History of Knee Surgery
For a patient with a history of knee surgery without current postoperative complications, use ICD-10-CM code Z87.81 (Personal history of [healed] traumatic fracture) or Z96.65 (Presence of artificial knee joint) if the patient has a knee prosthesis, or Z98.89 (Other specified postprocedural states) for general history of knee surgery.
Primary Code Selection Algorithm
The specific code depends on the type of knee surgery performed:
For patients with total knee arthroplasty (TKA): Use Z96.65 (Presence of artificial knee joint) as this indicates the current status of having a knee prosthesis 1
For patients with prior knee surgery but no prosthesis: Use Z98.89 (Other specified postprocedural states) to document the surgical history 2, 3
For orthopedic follow-up visits after uncomplicated TKA: The primary diagnosis code should reflect the reason for the encounter (e.g., routine follow-up), with Z96.65 as a secondary code 1
Clinical Context for Code Selection
When documenting for asymptomatic follow-up after TKA:
- The patient requires routine radiographic surveillance, which is typically performed annually or every other year for long-term monitoring (>10 years) 1
- Standing AP and lateral knee radiographs are the standard imaging modality (rated 9/9 as "usually appropriate") for asymptomatic TKA follow-up 1
- No additional advanced imaging (MRI, CT, bone scan) is appropriate for routine asymptomatic follow-up 1
Important Coding Considerations
Accuracy of ICD-10 coding for orthopedic procedures:
- ICD-10-CM codes demonstrate 95-96% accuracy when identifying hip and knee arthroplasty procedures in administrative databases 3
- For total knee arthroplasty specifically, sensitivity is 89%, specificity is 98%, positive predictive value is 97%, and negative predictive value is 93% 3
Critical pitfall to avoid:
- Do not use complication codes (such as those for infection, loosening, or pain) unless there is documented evidence of an active complication requiring evaluation or treatment 2, 4
- The transition from ICD-9 to ICD-10 showed relatively small discontinuities for most comorbidities in joint replacement patients, supporting the reliability of ICD-10 coding for this population 2
Documentation Requirements
For proper code assignment, the medical record should specify:
- The type of knee surgery performed (arthroscopy, ligament repair, meniscectomy, arthroplasty, etc.) 1, 3
- Whether a prosthetic device was implanted (requiring Z96.65) 1
- The laterality (right, left, or bilateral) 1, 3
- Whether this is a primary or revision procedure 3
- Current symptom status (asymptomatic vs. symptomatic) to guide appropriate code selection 1