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ICD-10 Coding for Flat Foot(M21.41, M21.42, Q66.52)

Complete ICD-10-CM coding and documentation guide for Flat Foot. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

Pes PlanusFallen Arches

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Related ICD-10 Code Ranges

Complete code families applicable to Flat Foot

M21.4-Primary Range

Acquired flat foot

This range covers acquired flat foot conditions, which are the most commonly coded forms of flat foot.

Q66.5-

Congenital flat foot

This range is used for congenital forms of flat foot, which are present from birth.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
M21.41Acquired flat foot, right footUse when the patient has acquired flat foot affecting the right foot.
  • Documentation of acquired status
  • Radiographic evidence of medial arch collapse
M21.42Acquired flat foot, left footUse when the patient has acquired flat foot affecting the left foot.
  • Documentation of acquired status
  • Radiographic evidence of medial arch collapse
Q66.52Congenital rigid flat foot, left footUse for congenital flat foot present since birth.
  • Documentation of congenital status
  • Presence since childhood

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 flat foot

Essential facts and insights about Flat Foot

The ICD-10 code for acquired flat foot is M21.41 for the right foot and M21.42 for the left foot.

Primary ICD-10-CM Codes for flat foot

M21.41
Acquired flat foot, right foot
Billable Code

Decision Criteria

clinical Criteria

  • Patient presents with acquired flat foot symptoms on the right foot.

documentation Criteria

  • Radiographic evidence supports acquired flat foot diagnosis.

Applicable To

  • Acquired pes planus of the right foot

Excludes

Clinical Validation Requirements

  • Documentation of acquired status
  • Radiographic evidence of medial arch collapse

Code-Specific Risks

  • Incorrectly coding as congenital
  • Omitting laterality

Coding Notes

  • Ensure documentation specifies acquired nature and laterality.
View Full Code Details

Ancillary Codes

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

Type 2 diabetes mellitus with diabetic neuropathy, unspecified

E11.40
Use when diabetes is a contributing factor to the flat foot condition.

Differential Codes

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

Congenital rigid flat foot, left foot

Q66.52
Presence since childhood and rigid deformity.

Acquired flat foot, left foot

M21.42
Developed after birth, often due to external factors.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting Flat Foot to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M21.41.

Impact

Clinical: Inaccurate treatment planning., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials or delays.

Mitigation Strategy

Always document laterality in the clinical note., Cross-check imaging reports for laterality.

Impact

Reimbursement: Claims may be denied or delayed., Compliance: Non-compliance with ICD-10 specificity requirements., Data Quality: Decreased accuracy in patient records.

Mitigation Strategy

Always use specific laterality codes (M21.41 or M21.42) when possible.

Impact

Reimbursement: Incorrect coding can lead to claim denials., Compliance: Failure to adhere to coding guidelines., Data Quality: Inaccurate clinical data affecting patient care.

Mitigation Strategy

Verify patient history and documentation to determine if the condition is acquired or congenital.

Impact

Failure to document laterality can lead to audit flags.

Mitigation Strategy

Ensure all clinical notes and imaging reports specify 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 Flat Foot, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for Flat Foot

Use these documentation templates to ensure complete and accurate documentation for Flat Foot. These templates include all required elements for proper coding and billing.

Acquired flat foot diagnosis

Specialty: Podiatry

Required Elements

  • Patient history
  • Physical examination findings
  • Radiographic evidence
  • Assessment and plan

Example Documentation

Assessment: Acquired pes planus, right foot (M21.41). Associated posterior tibial tendon insufficiency. Calcaneal pitch angle: 10.2° on weight-bearing X-ray. Plan: Custom orthotics, physical therapy referral.

Examples: Poor vs. Good Documentation

Poor Documentation Example
Flat foot noted.
Good Documentation Example
Acquired flexible flat foot, left, with medial arch collapse on weight-bearing, confirmed via calcaneal pitch angle <12.4° on lateral radiograph.
Explanation
The good example provides specific details about the condition, including laterality and radiographic confirmation, which are necessary for accurate coding.

Need help with ICD-10 coding for Flat Foot? Ask your questions below.

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