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ICD-10 Coding for Bilateral Plantar Fasciitis(M72.2)

Complete ICD-10-CM coding and documentation guide for Bilateral Plantar Fasciitis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

Plantar Fascial FibromatosisHeel Spur Syndrome

Related ICD-10 Code Ranges

Complete code families applicable to Bilateral Plantar Fasciitis

M72.2Primary Range

Plantar fascial fibromatosis

This range includes plantar fasciitis, which is the primary condition being documented.

Calcaneal spur

This range is relevant when a calcaneal spur is present alongside plantar fasciitis.

Key Information: ICD-10 code for bilateral plantar fasciitis

Essential facts and insights about Bilateral Plantar Fasciitis

The ICD-10 code for bilateral plantar fasciitis is M72.2, used when both feet are affected.

Primary ICD-10-CM Code for bilateral plantar fasciitis

Plantar fascial fibromatosis
Billable Code

Decision Criteria

clinical Criteria

  • Bilateral heel pain with imaging confirmation

coding Criteria

  • Avoid using for unilateral cases without specifying laterality

Applicable To

  • Plantar fasciitis

Excludes

  • Other specified disorders of soft tissue (M79.89)

Clinical Validation Requirements

  • Imaging showing plantar fascia thickening ≥4mm
  • Positive Windlass test bilaterally
  • Tenderness at medial calcaneal tubercle

Code-Specific Risks

  • Incorrectly using for unilateral cases without specifying laterality
  • Confusing with calcaneal spur without imaging confirmation

Coding Notes

  • Ensure documentation specifies bilateral involvement to support M72.2.

Ancillary Codes

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

Pain in foot, bilateral

M79.67
Use to document associated bilateral foot pain.

Other abnormalities of gait and mobility

R26.89
Use if gait abnormalities are present due to plantar fasciitis.

Differential Codes

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

Calcaneal spur, unspecified foot

M77.30
Use only if imaging confirms a calcaneal spur without plantar fasciitis.

Achilles tendinitis, bilateral

M76.62
Differentiate based on location of pain and imaging findings.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting Bilateral Plantar Fasciitis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M72.2.

Impact

Clinical: May lead to misdiagnosis or incomplete treatment., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials or payment delays.

Mitigation Strategy

Always specify laterality in documentation., Use imaging to confirm bilateral involvement.

Impact

Reimbursement: May lead to claim denials or incorrect DRG assignment., Compliance: Non-compliance with ICD-10 coding guidelines., Data Quality: Inaccurate patient records and data reporting.

Mitigation Strategy

Document 'bilateral' explicitly in the medical record.

Impact

Failure to document bilateral involvement can lead to audit findings.

Mitigation Strategy

Implement checklist for documentation of laterality in all plantar fasciitis cases.

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 Plantar Fasciitis, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for Bilateral Plantar Fasciitis

Use these documentation templates to ensure complete and accurate documentation for Bilateral Plantar Fasciitis. These templates include all required elements for proper coding and billing.

Definitive Diagnosis

Specialty: Podiatry

Required Elements

  • Patient history of bilateral heel pain
  • Physical exam findings
  • Imaging results

Example Documentation

Patient reports 6/10 sharp pain in both heels worst upon first morning steps. Physical exam reveals bilateral tenderness at plantar fascia origins. MRI confirms bilateral plantar fascia thickening (5mm right, 4.5mm left). Diagnosis: Bilateral plantar fasciitis.

Examples: Poor vs. Good Documentation

Poor Documentation Example
Patient has heel pain.
Good Documentation Example
Patient reports bilateral heel pain with tenderness at medial calcaneal tubercle. MRI confirms plantar fascia thickening bilaterally.
Explanation
The good example provides specific laterality and imaging confirmation, supporting the diagnosis.

Need help with ICD-10 coding for Bilateral Plantar Fasciitis? Ask your questions below.

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