ICD-10 Coding for Bilateral Lower Extremity Pain(M79.604, M79.605, G89.29)
Complete ICD-10-CM coding and documentation guide for Bilateral Lower Extremity Pain. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Bilateral Lower Extremity Pain
M79.60-M79.67Primary Range
Pain in limb
This range includes codes for pain in specific parts of the limbs, including bilateral cases which require separate codes for each side.
Other chronic pain
Used to indicate chronic pain when the site-specific codes do not capture chronicity.
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 the patient has documented pain specifically in the right leg. |
|
| M79.605 | Pain in left leg | Use when the patient has documented pain specifically in the left leg. |
|
| G89.29 | Other chronic pain | Use when chronic pain is present and site-specific codes do not capture chronicity. |
|
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 lower extremity pain
Essential facts and insights about Bilateral Lower Extremity Pain
Primary ICD-10-CM Codes for bilateral lower extremity pain
Decision Criteria
clinical Criteria
- Pain localized to the right leg without specific joint involvement.
Applicable To
- Right leg pain
Excludes
- Pain in right knee (M25.561)
Clinical Validation Requirements
- Documented pain in the right leg
- No confirmed etiology
Code-Specific Risks
- Risk of using unspecified codes when laterality is documented
Coding Notes
- Ensure laterality is documented to avoid unspecified codes.
M79.605 - Pain in left leg
Use when the patient has documented pain specifically in the left leg.
Applicable To
- Left leg pain
Excludes
- Pain in left knee (M25.562)
Clinical Validation Requirements
- Documented pain in the left leg
- No confirmed etiology
Coding Notes
Ensure laterality is documented to avoid unspecified codes.
G89.29 - Other chronic pain
Use when chronic pain is present and site-specific codes do not capture chronicity.
Applicable To
- Chronic pain not elsewhere classified
Excludes
- Acute pain (G89.1)
Clinical Validation Requirements
- Pain duration greater than 3 months
- Documentation of chronicity and impact on function
Coding Notes
Sequence 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.
Other chronic pain
G89.29Differential 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 Lower Extremity 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: Non-compliance with coding guidelines., Financial: Potential for claim denials.
Mitigation Strategy
Always document the duration and impact of chronic pain.
Impact
Reimbursement: May lead to claim denials or reduced reimbursement., Compliance: Non-compliance with ICD-10 specificity requirements., Data Quality: Decreases the accuracy of clinical data.
Mitigation Strategy
Always use specific codes for each side (e.g., M79.604 and M79.605).
Impact
Using unspecified codes when specific laterality is documented.
Mitigation Strategy
Ensure documentation specifies laterality and use corresponding codes.
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 Lower Extremity Pain, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Bilateral Lower Extremity Pain
Use these documentation templates to ensure complete and accurate documentation for Bilateral Lower Extremity Pain. These templates include all required elements for proper coding and billing.
Chronic bilateral lower leg pain
Specialty: NeurologyRequired Elements
- Pain duration
- Laterality
- Failed treatments
- Imaging results
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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