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v1.0.0
ICD-10 Guide
ICD-10 CodesR22.41

R22.41

Localized swelling, mass and lump, right lower limb

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/11/2025

Code Description

ICD-10 R22.41 is a billable code used to indicate a diagnosis of localized swelling, mass and lump, right lower limb.

Key Diagnostic Point:

Localized swelling, mass, or lump in the right lower limb can present as a palpable enlargement or abnormality in the tissue of the leg, ankle, or foot. This condition may arise from various underlying causes, including trauma, infection, inflammation, or neoplastic processes. Symptoms may include pain, tenderness, warmth, or redness in the affected area, and the mass may vary in size and consistency. Clinical evaluation often involves a thorough physical examination, imaging studies such as ultrasound or MRI, and possibly laboratory tests to assess for infection or inflammatory markers. The differential diagnosis can include conditions such as lipomas, hematomas, abscesses, or tumors. Accurate documentation of the size, location, and characteristics of the mass, as well as associated symptoms, is crucial for appropriate coding and management.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of potential underlying causes
  • Need for detailed clinical documentation
  • Differential diagnosis considerations
  • Variability in clinical presentation

Audit Risk Factors

  • Inadequate documentation of mass characteristics
  • Failure to specify laterality
  • Misdiagnosis leading to incorrect coding
  • Lack of supporting clinical findings

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Detailed history of the mass, including onset, duration, and associated symptoms; physical examination findings; and any relevant imaging or lab results.

Common Clinical Scenarios

Patients presenting with a new lump in the leg, often requiring evaluation for potential malignancy or infection.

Billing Considerations

Consideration of comorbidities that may affect the diagnosis and management of the swelling.

Emergency Medicine

Documentation Requirements

Acute assessment of the mass, including vital signs, pain level, and immediate interventions taken.

Common Clinical Scenarios

Acute trauma leading to hematoma formation or abscess development requiring urgent care.

Billing Considerations

Rapid assessment and documentation are critical, especially in cases of suspected infection or vascular compromise.

Coding Guidelines

Inclusion Criteria

Use R22.41 When
  • Follow the official ICD
  • CM guidelines for coding and reporting, ensuring that the code accurately reflects the clinical findings and that all documentation supports the diagnosis

Exclusion Criteria

Do NOT use R22.41 When
No specific exclusions found.

Related CPT Codes

10060CPT Code

Incision and drainage of abscess

Clinical Scenario

Used when an abscess is present in the localized swelling.

Documentation Requirements

Document the size, location, and nature of the abscess.

Specialty Considerations

Emergency medicine may require rapid documentation due to the acute nature of the condition.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of localized swelling and masses, improving the ability to capture clinical nuances and support better patient management.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of localized swelling and masses, improving the ability to capture clinical nuances and support better patient management.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of localized swelling and masses, improving the ability to capture clinical nuances and support better patient management.

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 should be documented to support the use of R22.41?

Documentation should include the size, location, and characteristics of the mass, associated symptoms, and any relevant imaging or lab results.