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ICD-10 Guide
ICD-10 CodesM21.162

M21.162

Billable

Varus deformity, not elsewhere classified, left knee

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/17/2025

Code Description

ICD-10 M21.162 is a billable code used to indicate a diagnosis of varus deformity, not elsewhere classified, left knee.

Key Diagnostic Point:

Varus deformity of the knee, commonly referred to as 'bowleggedness', is characterized by an inward angulation of the knee joint, resulting in a misalignment of the lower extremity. This condition can be acquired due to various factors, including osteoarthritis, trauma, or developmental issues. In adults, varus deformity often leads to increased stress on the medial compartment of the knee, which can exacerbate pain and functional limitations. Patients may present with symptoms such as knee pain, stiffness, and difficulty with weight-bearing activities. The deformity can also lead to compensatory changes in gait and posture, potentially resulting in secondary conditions affecting the hips and ankles. Treatment options may include physical therapy, bracing, or surgical interventions such as osteotomy to correct the alignment. Accurate coding of varus deformity is essential for appropriate management and reimbursement, as it reflects the complexity of the patient's condition and the necessity for targeted interventions.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between acquired and congenital deformities
  • Identifying the specific location and severity of the deformity
  • Understanding the underlying causes and associated conditions
  • Documenting the impact on function and quality of life

Audit Risk Factors

  • Inadequate documentation of the deformity's severity
  • Failure to specify the laterality of the condition
  • Lack of evidence for associated symptoms or functional limitations
  • Misclassification of the deformity type (acquired vs. congenital)

Specialty Focus

Medical Specialties

Orthopedics

Documentation Requirements

Detailed clinical notes including physical examination findings, imaging results, and treatment plans.

Common Clinical Scenarios

Patients presenting with knee pain, difficulty walking, or a history of trauma.

Billing Considerations

Ensure to document any prior treatments or interventions related to the varus deformity.

Physical Therapy

Documentation Requirements

Progress notes detailing functional assessments, treatment goals, and patient responses to therapy.

Common Clinical Scenarios

Patients undergoing rehabilitation post-surgery or those receiving conservative management for knee pain.

Billing Considerations

Document the impact of the deformity on mobility and daily activities.

Coding Guidelines

Inclusion Criteria

Use M21.162 When
  • Follow the official ICD
  • CM coding guidelines, ensuring accurate documentation of the condition's laterality and any associated complications

Exclusion Criteria

Do NOT use M21.162 When
  • Exclude congenital deformities unless specified

Related ICD-10 Codes

Related CPT Codes

27447CPT Code

Osteotomy, knee, medial or lateral

Clinical Scenario

Used for surgical correction of varus deformity in the knee.

Documentation Requirements

Pre-operative assessment, surgical notes, and post-operative follow-up.

Specialty Considerations

Orthopedic surgeons should document the rationale for surgical intervention.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of conditions like varus deformity, improving the accuracy of patient records and facilitating better treatment planning.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of conditions like varus deformity, improving the accuracy of patient records and facilitating better treatment planning.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of conditions like varus deformity, improving the accuracy of patient records and facilitating better treatment planning.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What is the difference between varus and valgus deformity?

Varus deformity refers to inward angulation of the knee, while valgus deformity refers to outward angulation. Both conditions can affect knee alignment and function.