ICD-10
International Classification of Diseases codes used to identify diagnoses. Your ICD-10 code for osteoarthritis determines what treatments insurance will cover.
Extended Definition
ICD-10 codes are alphanumeric codes that identify specific diagnoses and health conditions. Insurance companies require accurate ICD-10 codes to determine coverage and ensure treatments are medically appropriate for the diagnosis.
Common ICD-10 Codes for Joint Pain
Knee Osteoarthritis:
- M17.11: Primary OA, right knee
- M17.12: Primary OA, left knee
- M17.0: Bilateral primary OA of knee
Hip Osteoarthritis:
- M16.11: Primary OA, right hip
- M16.12: Primary OA, left hip
- M16.0: Bilateral primary OA of hip
Other Relevant Codes:
- M25.561: Pain in right knee
- M25.562: Pain in left knee
- M79.3: Panniculitis (inflammation)
Why ICD-10 Codes Matter
Coverage determination:
- Correct code = covered treatment
- Wrong code = potential denial
- Specificity matters (left vs. right, primary vs. secondary)
Example: HA injections covered for M17.11 (knee OA) but may be denied for M25.561 (knee pain) without OA diagnosis.
Checking Your Diagnosis Codes
On your medical records and bills:
- Find the ICD-10 code listed
- Verify it matches your condition
- Ensure laterality is correct (left/right)
- Check that it supports the treatment billed
If Codes Are Wrong
- Contact your doctor’s office
- Request correction before billing
- May need amended records
- Can affect future coverage
Primary vs. Secondary OA
Primary (idiopathic): M17.1x
- Cause unknown
- Age-related wear
Secondary: M17.3x
- Due to other condition
- Post-traumatic, post-surgical, etc.
Accurate coding helps ensure proper treatment coverage.
Related Terms
More Insurance Terms
View allAppeal
A formal request to have your insurance company reconsider a denied claim or coverage decision. You have the right to appeal most insurance denials, including Medicare decisions.
Coinsurance
Your share of the costs of a covered service, calculated as a percentage. With Medicare Part B, you pay 20% coinsurance after meeting your deductible.
CPT Code
Current Procedural Terminology codes used by healthcare providers to identify specific medical services for billing. Each joint injection, office visit, or therapy session has a specific CPT code.
Covered Service
A healthcare service that your insurance plan includes in your benefits and will help pay for, assuming you meet all requirements like deductibles and prior authorization.
Deductible
The amount you must pay out-of-pocket for healthcare services before your insurance starts paying. Medicare Part B has an annual deductible of $240 (2024).