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v1.0.0
ICD-10 Guide
ICD-10 CodesM21.612

M21.612

Billable

Bunion of left foot

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

Code Description

ICD-10 M21.612 is a billable code used to indicate a diagnosis of bunion of left foot.

Key Diagnostic Point:

A bunion, or hallux valgus, is a common foot deformity characterized by a lateral deviation of the great toe (hallux) at the metatarsophalangeal joint. This condition often results in a prominent bony bump on the inner side of the foot, leading to pain, inflammation, and difficulty in wearing shoes. Acquired bunions can develop due to various factors, including genetic predisposition, inappropriate footwear, and certain medical conditions that affect foot structure. The left foot is specifically affected in this code, which is crucial for accurate documentation and treatment planning. Patients may experience symptoms such as swelling, redness, and tenderness around the bunion, and they may report difficulty with ambulation or performing daily activities. Treatment options range from conservative measures, such as orthotics and anti-inflammatory medications, to surgical interventions aimed at realigning the toe and alleviating pain. Corrective procedures may include osteotomy, exostectomy, or arthrodesis, depending on the severity of the deformity and the patient's overall health status.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Specificity of the location (left foot) is required.
  • Differentiation from other toe deformities is necessary.
  • Documentation must support the diagnosis and treatment plan.
  • Potential for co-morbid conditions affecting foot health.

Audit Risk Factors

  • Inadequate documentation of symptoms and treatment.
  • Failure to specify laterality.
  • Misclassification of bunion type.
  • Lack of supporting clinical evidence for surgical procedures.

Specialty Focus

Medical Specialties

Podiatry

Documentation Requirements

Detailed clinical notes on the patient's foot structure, symptoms, and treatment history.

Common Clinical Scenarios

Patients presenting with pain and deformity in the left foot, requiring assessment for surgical intervention.

Billing Considerations

Ensure that all conservative treatments are documented before considering surgical options.

Orthopedics

Documentation Requirements

Comprehensive evaluation of foot mechanics and alignment, including imaging studies.

Common Clinical Scenarios

Patients with advanced bunion deformities requiring surgical correction.

Billing Considerations

Document any co-existing foot conditions that may influence treatment decisions.

Coding Guidelines

Inclusion Criteria

Use M21.612 When
  • Follow the official ICD
  • CM coding guidelines, ensuring accurate documentation of the condition's laterality and severity
  • Include any relevant co
  • morbidities that may affect treatment

Exclusion Criteria

Do NOT use M21.612 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

28292CPT Code

Osteotomy, first metatarsal

Clinical Scenario

Used for surgical correction of a bunion when conservative measures fail.

Documentation Requirements

Pre-operative assessment, imaging results, and detailed surgical notes.

Specialty Considerations

Podiatrists and orthopedic surgeons must document the rationale for surgery.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for greater specificity in coding bunions, including laterality, which aids in better tracking of treatment outcomes and resource allocation.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for greater specificity in coding bunions, including laterality, which aids in better tracking of treatment outcomes and resource allocation.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for greater specificity in coding bunions, including laterality, which aids in better tracking of treatment outcomes and resource allocation.

Resources

Clinical References

  • •
    American Podiatric Medical Association

Coding & Billing References

  • •
    American Podiatric Medical Association

Frequently Asked Questions

What is the difference between M21.612 and M21.611?

M21.612 refers specifically to a bunion on the left foot, while M21.611 refers to a bunion on the right foot. Accurate coding requires specifying the affected side.