ICD-10-CM Billable Code

M76.42

Tibial collateral bursitis [Pellegrini-Stieda], left leg

Clinical Classification Guidelines

Medical Intelligence & Overview

Tibial collateral bursitis, also known as Pellegrini-Stieda, is an inflammation of the bursa located near the tibial collateral ligament in the knee, specifically affecting the left leg in this context. The bursae are small fluid-filled sacs that act as cushions to reduce friction between tissues such as muscles, tendons, and bones. When these bursae become inflamed, it can cause pain, swelling, and limited movement in the knee joint. This condition primarily affects individuals who have experienced trauma or repetitive stress to the knee area, and understanding the causes, symptoms, and management options can help in seeking appropriate care.

Causes & Symptoms

Clinical Causes: Knee trauma or injury, such as a direct blow, fall, or twisting injury Repetitive knee movements or overuse, especially in athletes or active individuals Degenerative changes in the knee joint due to aging or osteoarthritis Previous surgical procedures involving the knee Infections or inflammatory conditions affecting the knee area

Key Symptoms: Localized pain and tenderness along the inner side of the knee, especially near the tibial collateral ligament Swelling or thickening around the affected bursa Limited range of motion or stiffness in the knee joint Warmth or redness in the skin over the affected area Discomfort that worsens with movement or activity

Diagnostic & Treatment

Diagnosis Path: Diagnosis typically involves a physical examination where a healthcare provider assesses tenderness, swelling, and joint movement. Imaging tests such as X-rays can help visualize bony changes and rule out other conditions. Ultrasound imaging may be used to evaluate the bursae and surrounding soft tissues for inflammation or fluid accumulation. In some cases, aspiration of fluid from the bursa for laboratory analysis may be performed to identify infection or other underlying issues.

Treatment Protocols: Management of tibial collateral bursitis generally includes measures to reduce inflammation and alleviate symptoms, such as: - Rest and activity modification to prevent further irritation - Applying ice packs to reduce swelling and pain - Nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief and inflammation control - Physical therapy to strengthen the muscles around the knee and improve joint stability - Aspiration of excess fluid from the bursa if swelling is significant - Corticosteroid injections to decrease inflammation in persistent cases In cases where infection is present, antibiotics may be necessary. Surgical intervention is rarely required but may be considered if conservative treatments fail or if structural damage is significant.

Reimbursement claims with a date of service on or after October 1, 2015 require the use of ICD-10-CM codes.

Clinical Advice & FAQs

Billing Guidance

Is M76.42 a billable ICD-10 code?
Yes, M76.42 is a specific, billable code that can be used to indicate a diagnosis for reimbursement purposes.

Documentation

How do I report M76.42?
Clinical documentation must specify the nature of Tibial collateral bursitis [Pellegrini-Stieda], left leg and any associated comorbidities for accurate reporting.

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