ICD-10 Coding for Bilateral Leg Pain(M79.604, M79.605, G89.29)
Complete ICD-10-CM coding and documentation guide for Bilateral Leg Pain. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Bilateral Leg Pain
M79.60-M79.66Primary Range
Pain in limb, hand, foot, fingers and toes
This range includes codes for pain in specific limbs, including bilateral leg pain when documented separately for each leg.
Chronic pain
Used to indicate chronic pain when the duration is over 3 months and is documented alongside site-specific codes.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| M79.604 | Pain in right leg | Use when pain is specifically documented in the right leg. |
|
| M79.605 | Pain in left leg | Use when pain is specifically documented in the left leg. |
|
| G89.29 | Other chronic pain | Use when chronic pain is documented and needs to be coded alongside site-specific pain codes. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for bilateral leg pain
Essential facts and insights about Bilateral Leg Pain
Primary ICD-10-CM Codes for bilateral leg pain
Decision Criteria
clinical Criteria
- Pain documented in the right leg
Applicable To
- Right leg pain
Excludes
- Pain in right knee (M25.561)
Clinical Validation Requirements
- Documentation of pain in the right leg
- Physical exam findings supporting right leg pain
Code-Specific Risks
- Risk of incorrect coding if laterality is not specified
Coding Notes
- Ensure laterality is documented to avoid using unspecified codes.
M79.605 - Pain in left leg
Use when pain is specifically documented in the left leg.
Applicable To
- Left leg pain
Excludes
- Pain in left knee (M25.562)
Clinical Validation Requirements
- Documentation of pain in the left leg
- Physical exam findings supporting left leg pain
Coding Notes
Ensure laterality is documented to avoid using unspecified codes.
G89.29 - Other chronic pain
Use when chronic pain is documented and needs to be coded alongside site-specific pain codes.
Applicable To
- Chronic pain not elsewhere classified
Excludes
- Acute pain (G89.1)
Clinical Validation Requirements
- Pain duration documented as greater than 3 months
- Functional impact or chronicity documented
Coding Notes
Sequence G89.29 first if the encounter is for pain management.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Bilateral Leg Pain to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M79.604.
Impact
Clinical: Inaccurate representation of patient's condition., Regulatory: Potential audit issues., Financial: Denial of claims for chronic pain management.
Mitigation Strategy
Always document pain duration and impact., Use standardized templates for chronic pain.
Impact
Reimbursement: Incorrect coding may lead to claim denials., Compliance: Non-compliance with coding guidelines., Data Quality: Decreased accuracy in patient records.
Mitigation Strategy
Code both M79.604 and M79.605 for bilateral pain.
Impact
Using unspecified codes when laterality is documented.
Mitigation Strategy
Ensure documentation specifies right or left leg.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Bilateral Leg Pain, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Bilateral Leg Pain
Use these documentation templates to ensure complete and accurate documentation for Bilateral Leg Pain. These templates include all required elements for proper coding and billing.
Chronic Bilateral Leg Pain
Specialty: Primary CareRequired Elements
- Patient history
- Pain duration
- Laterality
- Functional impact
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Bilateral Leg Pain? Ask your questions below.