ICD-10 Coding for Left Lower Leg Pain(M79.662, S86.912A)
Complete ICD-10-CM coding and documentation guide for Left Lower Leg Pain. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Left Lower Leg Pain
M79.60-M79.67Primary Range
Other soft tissue disorders, not elsewhere classified
This range includes codes for pain in various parts of the leg, with M79.662 specifically for left lower leg pain.
Injury of muscle and tendon at lower leg level
This range includes codes for strains and injuries to muscles and tendons in the lower leg.
Atherosclerosis of native arteries of extremities
This range includes codes for vascular conditions that can cause leg pain, such as atherosclerosis.
Lesion of sciatic nerve
This range includes codes for nerve-related pain that can affect the lower leg.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| M79.662 | Pain in left lower leg | Use when the patient presents with nonspecific pain localized to the left lower leg without a specific injury or underlying condition. |
|
| S86.912A | Strain of unspecified muscle and tendon at lower leg level, left leg, initial encounter | Use for initial encounters when there is a confirmed strain of the muscle or tendon in the left lower leg. |
|
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 left lower leg pain
Essential facts and insights about Left Lower Leg Pain
Primary ICD-10-CM Codes for left lower leg pain
Decision Criteria
clinical Criteria
- Pain is localized to the left lower leg without specific injury
documentation Criteria
- Documentation includes specific location and nature of pain
Applicable To
- Chronic left lower leg pain
- Acute left lower leg pain
Clinical Validation Requirements
- Patient reports pain localized to the left lower leg
- Physical exam shows tenderness in the left lower leg
- No evidence of trauma or specific injury
Code-Specific Risks
- Risk of under-documentation if pain location is not specified
- Potential for incorrect coding if underlying cause is not ruled out
Coding Notes
- Ensure documentation specifies the exact location and nature of the pain to avoid miscoding.
S86.912A - Strain of unspecified muscle and tendon at lower leg level, left leg, initial encounter
Use for initial encounters when there is a confirmed strain of the muscle or tendon in the left lower leg.
Applicable To
- Acute strain of left lower leg muscles
Excludes
- Chronic strain (M62.40)
Clinical Validation Requirements
- Patient reports acute onset of pain following physical activity
- Physical exam shows tenderness and swelling in the affected area
- Imaging confirms muscle or tendon strain
Coding Notes
Ensure documentation includes the mechanism of injury and clinical findings supporting the strain diagnosis.
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 Left Lower Leg Pain to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M79.662.
Impact
Clinical: May lead to inappropriate treatment if the wrong side is treated., Regulatory: Non-compliance with coding standards requiring laterality., Financial: Potential for denied claims due to incomplete documentation.
Mitigation Strategy
Always include laterality in documentation., Use templates that prompt for laterality.
Impact
Reimbursement: May lead to incorrect DRG assignment and reimbursement issues., Compliance: Could result in non-compliance with coding guidelines., Data Quality: Affects the accuracy of clinical data and patient records.
Mitigation Strategy
Ensure documentation specifies the exact location of the pain to use M79.662 appropriately.
Impact
Audits may focus on whether the documentation specifies the exact location of pain.
Mitigation Strategy
Use detailed templates and ensure thorough documentation of pain location.
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 Left Lower Leg Pain, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Left Lower Leg Pain
Use these documentation templates to ensure complete and accurate documentation for Left Lower Leg Pain. These templates include all required elements for proper coding and billing.
Chronic left lower leg pain in an orthopedic setting
Specialty: OrthopedicsRequired Elements
- Patient history
- Pain description
- Physical exam findings
- Imaging results
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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