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ICD-10 Coding for Pain in Lower Extremity(M79.661, M79.662, M79.669)

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

Also known as:

Leg PainLower Leg PainPain in Leg

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Related ICD-10 Code Ranges

Complete code families applicable to Pain in Lower Extremity

M79.66Primary Range

Pain in lower leg

This range covers pain specifically located in the lower extremity without a specified underlying condition.

G89.2

Chronic pain

Used for chronic pain management scenarios, often sequenced first when the encounter is primarily for pain management.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
M79.661Pain in right lower legUse when pain is localized to the right lower leg without an identified underlying cause.
  • Patient reports sharp, localized pain in the right lower leg
  • Physical examination reveals tenderness to palpation
M79.662Pain in left lower legUse when pain is localized to the left lower leg without an identified underlying cause.
  • Patient reports sharp, localized pain in the left lower leg
  • Physical examination reveals tenderness to palpation
M79.669Pain in unspecified lower legUse when pain is present in the lower leg but laterality is not specified.
  • Patient reports generalized pain in the lower leg
  • Physical examination lacks specific localization

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 pain in lower extremity

Essential facts and insights about Pain in Lower Extremity

The ICD-10 code for pain in the lower extremity is M79.66, with specific codes for right (M79.661) and left (M79.662) lower leg pain.

Primary ICD-10-CM Codes for pain lower extremity

M79.661
Pain in right lower leg
Billable Code

Decision Criteria

clinical Criteria

  • Pain localized to the right lower leg without systemic symptoms.

Applicable To

  • Localized pain in right lower leg

Excludes

  • Pain due to underlying condition

Clinical Validation Requirements

  • Patient reports sharp, localized pain in the right lower leg
  • Physical examination reveals tenderness to palpation

Code-Specific Risks

  • Risk of unspecified laterality if not documented

Coding Notes

  • Ensure laterality is specified to avoid unspecified coding.
View Full Code Details

Ancillary Codes

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

Chronic pain due to trauma

G89.21
Use when chronic pain is due to a traumatic event and is the focus of treatment.

Differential Codes

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

Pain in left lower leg

M79.662
Use when pain is localized to the left lower leg.

Pain in right lower leg

M79.661
Use when pain is localized to the right lower leg.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting Pain in Lower Extremity to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M79.661.

Impact

Clinical: May lead to incorrect treatment., Regulatory: Increases risk of non-compliance., Financial: Potential for reduced reimbursement.

Mitigation Strategy

Always document the side of the body affected., Use templates that prompt for laterality.

Impact

Reimbursement: May lead to lower reimbursement rates., Compliance: Increases risk of audit due to lack of specificity., Data Quality: Reduces accuracy of health records.

Mitigation Strategy

Always document and code the specific side of the body affected.

Impact

Using unspecified codes increases audit risk.

Mitigation Strategy

Always document and code specific laterality.

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 Lower Extremity, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for Pain in Lower Extremity

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

Chronic pain management

Specialty: Pain Management

Required Elements

  • Pain location and laterality
  • Pain intensity and character
  • Duration and exacerbating factors
  • Treatment history and response

Example Documentation

Patient reports chronic sharp pain in the right lower leg, 6/10 on VAS, worsened by walking.

Examples: Poor vs. Good Documentation

Poor Documentation Example
Leg pain present.
Good Documentation Example
Sharp, localized pain in right lower leg at mid-calf region, exacerbated by weight-bearing.
Explanation
The good example provides specific location, character, and exacerbating factors.

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

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