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ICD-10 Coding for Pain in Left Lower Leg(M79.662)

Complete ICD-10-CM coding and documentation guide for Pain in Left Lower Leg. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

Left Lower Leg PainPain in Left Calf

Related ICD-10 Code Ranges

Complete code families applicable to Pain in Left Lower Leg

M79.60-M79.66Primary Range

Other soft tissue disorders, not elsewhere classified

This range includes codes for pain in specific parts of the leg, including the lower leg.

Injury of muscle and tendon at lower leg level

This range is relevant for cases where the pain is due to a specific injury or strain.

Sciatica

This range is used when the pain is referred from the spine, such as in radiculopathy.

Key Information: ICD-10 code for pain in left lower leg

Essential facts and insights about Pain in Left Lower Leg

The ICD-10 code for pain in the left lower leg is M79.662, used for localized pain without a specific cause.

Primary ICD-10-CM Code for pain left lower leg

Pain in left lower leg
Billable Code

Decision Criteria

clinical Criteria

  • Pain localized to the left lower leg without radiation or specific injury.

documentation Criteria

  • Documentation must include negative imaging and normal vascular/neurological exams.

Applicable To

  • Localized pain in the left lower leg

Excludes

  • Pain due to injury (S86.9-)
  • Referred pain from spine (M54.3-)

Clinical Validation Requirements

  • Negative imaging for structural abnormalities
  • Normal vascular and neurological exams

Code-Specific Risks

  • Risk of using unspecified codes when laterality is documented

Coding Notes

  • Ensure documentation specifies the exact location and laterality of the pain.

Ancillary Codes

Additional codes that should be used in conjunction with the main diagnosis codes when applicable.

Strain of muscle, fascia and tendon of lower leg, left leg, initial encounter

S86.912A
Use when there is a confirmed strain or injury to the left lower leg.

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Lumbosacral radiculopathy, left

M54.36
Use when pain radiates from the spine with positive neurological findings.

Peripheral vascular disease, unspecified

I73.9
Use when pain is associated with claudication symptoms and diminished pulses.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting Pain in Left Lower Leg 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 misdiagnosis or inappropriate treatment., Regulatory: Increases risk of non-compliance with coding standards., Financial: Potential for denied claims or reduced reimbursement.

Mitigation Strategy

Train staff on importance of detailed documentation, Use templates that prompt for specific details

Impact

Reimbursement: May lead to reduced reimbursement rates., Compliance: Increases risk of audit due to lack of specificity., Data Quality: Decreases accuracy of clinical data.

Mitigation Strategy

Always specify laterality: 'Left' > 'unspecified'

Impact

Using unspecified codes when specific ones are available.

Mitigation Strategy

Ensure documentation supports the most specific code.

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 Pain in Left Lower Leg, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for Pain in Left Lower Leg

Use these documentation templates to ensure complete and accurate documentation for Pain in Left Lower Leg. These templates include all required elements for proper coding and billing.

Chronic pain management

Specialty: Orthopedics

Required Elements

  • Pain location and duration
  • Negative imaging results
  • Normal vascular and neurological exams

Example Documentation

38F with 2-week history of left anterior shin pain (VAS 6/10). No trauma. Tenderness to palpation over tibialis anterior. Normal ankle ROM. X-ray negative for fracture. Diagnosis: M79.662

Examples: Poor vs. Good Documentation

Poor Documentation Example
Patient complains of leg pain. Advised rest.
Good Documentation Example
Subjective: Sharp, non-radiating left calf pain x1 week (VAS 4/10). No trauma. Objective: TTP left soleus, strength 5/5, pulses 2+, negative Homan's sign. Assessment: M79.662 - Pain left lower leg. Plan: PT referral.
Explanation
The good example provides specific location, duration, and negative findings, supporting the code choice.

Need help with ICD-10 coding for Pain in Left Lower Leg? Ask your questions below.

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