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ICD-10 Coding for Pain in Right Leg(M79.604, M79.651, M79.607)

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

Also known as:

Right Leg PainPain in Right Lower Limbright lower limb pain

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Related ICD-10 Code Ranges

Complete code families applicable to Pain in Right Leg

M79.60-M79.67Primary Range

Other and unspecified soft tissue disorders, not elsewhere classified

This range includes codes for pain in specific parts of the leg, such as the thigh, lower leg, and ankle.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
M79.604Pain in right legUse when pain is generalized in the right leg without specific localization.
  • Documentation of pain location and duration
  • Exclusion of trauma or systemic causes
M79.651Pain in right thighUse when pain is specifically localized to the right thigh.
  • Pain localized to quadriceps/hamstrings
  • Positive Trendelenburg sign or iliac crest tenderness
M79.607Pain in right lower legUse when pain is specifically localized to the right lower leg.
  • Shin splints or calf tenderness on palpation
  • Doppler ultrasound ruling out DVT

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 right leg

Essential facts and insights about Pain in Right Leg

The ICD-10 code for generalized pain in the right leg is M79.604, used when the pain is not localized to a specific part of the leg.

Primary ICD-10-CM Codes for pain right leg

M79.604
Pain in right leg
Billable Code

Decision Criteria

clinical Criteria

  • Pain is generalized in the right leg without specific localization.

documentation Criteria

  • Documentation includes pain duration and absence of trauma.

Applicable To

  • Generalized pain in the right leg

Excludes

Clinical Validation Requirements

  • Documentation of pain location and duration
  • Exclusion of trauma or systemic causes

Code-Specific Risks

  • Using this code without specifying the location can lead to denials.

Coding Notes

  • Ensure documentation specifies the absence of trauma and the duration of pain.
View Full Code Details

Ancillary Codes

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

Chronic pain, not elsewhere classified

G89.29
Use for chronic pain management encounters.

Differential Codes

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

Meralgia paresthetica

G57.12
Requires EMG confirmation of lateral femoral cutaneous nerve compression.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting Pain in Right Leg to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M79.604.

Impact

Clinical: May lead to incorrect diagnosis and treatment., Regulatory: Non-compliance with documentation standards., Financial: Potential for claim denials.

Mitigation Strategy

Train staff on documentation requirements., Use templates to ensure completeness.

Impact

Reimbursement: May lead to claim denials or reduced reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Decreases the accuracy of clinical data.

Mitigation Strategy

Always document and code the specific location of pain.

Impact

Using unspecified codes without supporting documentation.

Mitigation Strategy

Ensure documentation specifies location and duration of pain.

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 Right Leg, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for Pain in Right Leg

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

Orthopedic Progress Note

Specialty: Orthopedics

Required Elements

  • Subjective description of pain
  • Objective findings
  • Assessment and plan

Example Documentation

**Subjective**: "Right leg pain localized to mid-calf ×4 weeks. No trauma. Aggravated by walking >15 mins." **Objective**: Tender to palpation: Right soleus. Strength: 4/5 plantar flexion. Imaging: X-ray negative for fracture. **Assessment**: M79.607 (Pain in right lower leg). **Plan**: PT referral, NSAIDs.

Examples: Poor vs. Good Documentation

Poor Documentation Example
Patient complains of leg pain.
Good Documentation Example
Right lateral calf pain for 3 weeks, 7/10 intensity, no trauma. Negative X-ray for fracture. Tender to palpation at gastrocnemius.
Explanation
The good example provides specific location, duration, intensity, and clinical findings.

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

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