Unequal limb length (acquired), right tibia
ICD-10 M21.761 is a billable code used to indicate a diagnosis of unequal limb length (acquired), right tibia.
Unequal limb length, also known as limb length discrepancy, refers to a condition where one limb is shorter than the other due to various acquired factors. In the case of M21.761, the focus is specifically on the right tibia. This condition can arise from several causes, including trauma, surgical interventions, infections, or diseases that affect bone growth and development. Acquired limb length discrepancies can lead to functional impairments, gait abnormalities, and increased risk of osteoarthritis in the affected limb. Clinically, patients may present with complaints of pain, difficulty walking, or compensatory postures. Diagnosis typically involves a thorough clinical examination, imaging studies such as X-rays or MRI, and sometimes gait analysis. Treatment options vary based on the severity of the discrepancy and may include orthopedic interventions such as limb lengthening procedures, corrective osteotomies, or the use of orthotic devices. Accurate coding of this condition is essential for appropriate management and reimbursement.
Detailed clinical notes including history of the condition, physical examination findings, imaging results, and treatment plans.
Patients presenting with post-traumatic limb length discrepancies, those requiring corrective osteotomies, or individuals with chronic pain due to unequal limb lengths.
Orthopedic surgeons must document the specific nature of the acquired condition and any surgical interventions performed.
Assessment of functional limitations, treatment goals, and progress notes detailing interventions related to limb length discrepancies.
Patients undergoing rehabilitation post-surgery for limb lengthening or those receiving gait training due to discrepancies.
Physical therapists should document the impact of the limb length discrepancy on mobility and function.
Used in cases where surgical intervention is required to correct limb length discrepancy.
Surgical notes must detail the procedure performed, indications, and any pre-operative assessments.
Orthopedic surgeons should ensure that all relevant clinical information is documented to support the procedure.
Congenital limb length discrepancy is present at birth and is often due to genetic factors, while acquired limb length discrepancy develops after birth due to trauma, surgery, or disease.
