Musculoskeletal condition M76.01 — ICD-10 M76.01

ICD-10: M76.01 | Category: Soft Tissue Disorders | Billable: Yes

ICD-10 code M76.01 refers to pes anserinus bursitis, a common musculoskeletal condition characterized by inflammation of the bursa located at the medial aspect of the knee, where the tendons of three muscles—the sartorius, gracilis, and semitendinosus—attach to the tibia. This condition often presents with pain and tenderness in the knee, particularly during activities that involve bending or squatting. It is prevalent among athletes and individuals engaged in repetitive activities that strain the knee joint.

The pes anserinus, meaning "goose's foot" in Latin, is a confluence of tendons from three muscles originating from the pelvis and inserting onto the anteromedial surface of the proximal tibia. These muscles include:

• Sartorius: A long muscle that flexes, abducts, and laterally rotates the hip.
• Gracilis: A muscle that adducts the thigh and flexes the knee.
• Semitendinosus: One of the hamstring muscles that flexes the knee and extends the hip.

The bursa located beneath these tendons serves to reduce friction during movement, particularly when flexing and extending the knee. Biomechanically, excessive stress on this region can lead to microtrauma and inflammation of the bursa, resulting in bursitis.

Patient presents with bilateral knee pain and tenderness along the medial aspect of the knees after participating in a long-distance running event. The physician notes that the patient has recently increased their running distance without adequate conditioning. Code as M76.01 because the diagnosis of Pes Anserinus Tendinitis is supported by the documentation of location-specific tenderness, recent overuse activity, and the absence of other significant knee pathologies.

To support medical necessity and prevent claim denials for ICD-10 code M76.01, the following documentation elements are essential:

1. Comprehensive Patient History: Document a detailed history including the onset, duration, and exacerbating factors of the knee pain.
2. Physical Examination Findings: Clearly indicate tenderness at the pes anserinus site and any limitations in range of motion or strength.
3. Diagnosis Justification: Include a clear rationale for the diagnosis of Pes Anserinus Tendinitis, linking it to specific activities or conditions that may have led to the injury.
4. Treatment Plan: Outline the treatment recommendations, including any referrals to physical therapy, medications prescribed, and follow-up care plans.
5. Patient Education: Document discussions with the patient regarding activity modifications and preventive strategies to reduce recurrence.

Subjective: A 34-year-old female presents with complaints of pain and swelling localized to the medial aspect of her right knee. The pain started approximately three weeks ago after increasing her running distance from 3 to 6 miles daily. The patient describes the pain as sharp during activities and dull at rest. Objective: On physical examination, there is tenderness over the pes anserinus insertion site with mild swelling. Range of motion is intact, but there is pain on resisted knee flexion. No signs of joint effusion or instability are noted. Assessment: Pes Anserinus Tendinitis (ICD-10 Code M76.01) due to overuse from increased running distance. Plan: Recommend rest, ice application for 20 minutes several times a day, and non-steroidal anti-inflammatory drugs (NSAIDs) for pain management. Initiate a physical therapy referral focusing on stretching and strengthening exercises for the hip and knee. Schedule a follow-up appointment in four weeks to assess progress.

When diagnosing pes anserinus bursitis, it is crucial to differentiate it from other conditions that may present similarly:

• M75.52: Shoulder bursitis
• M70.60: Trochanteric bursitis
• M17.9: Osteoarthritis of knee
• M23.2: Meniscus tear
• M25.561: Pain in right knee
• M25.562: Pain in left knee

Each condition has its unique treatment pathways and implications for rehabilitation.

Accurate documentation is critical for billing purposes under ICD-10 code M76.01:

1. Document patient history including onset, duration, and nature of symptoms.
2. Include findings from physical examination detailing tenderness, swelling, and functional limitations.
3. Record any imaging studies performed along with their findings supporting your diagnosis.
4. Clearly outline treatment plans including conservative measures taken before progressing to more invasive options if necessary.

Ensure all documentation aligns with billing requirements for reimbursement compliance.