Varus deformity, not elsewhere classified, right ankle
ICD-10 M21.171 is a billable code used to indicate a diagnosis of varus deformity, not elsewhere classified, right ankle.
Varus deformity of the ankle is characterized by an inward angulation of the distal segment of a bone or joint, leading to a misalignment that can affect gait and overall mobility. This condition can be acquired due to various factors including trauma, degenerative diseases, or post-surgical changes. Patients may present with symptoms such as pain, swelling, and difficulty in weight-bearing activities. The right ankle specifically indicates the affected side, which is crucial for treatment planning. Varus deformities can lead to secondary complications such as arthritis or instability if left untreated. Treatment options may include physical therapy, orthotic devices, or surgical interventions such as osteotomy or arthrodesis to correct the alignment and restore function. Accurate coding is essential for proper reimbursement and to reflect the complexity of the condition in clinical documentation.
Detailed clinical notes including history, physical examination findings, imaging results, and treatment plans.
Patients presenting with ankle pain, history of trauma, or previous surgeries leading to deformity.
Ensure to document any prior interventions and their outcomes to justify the current diagnosis.
Progress notes detailing functional assessments, treatment goals, and patient responses to therapy.
Patients undergoing rehabilitation post-surgery for varus deformity correction.
Document specific functional limitations and progress towards rehabilitation goals.
Used when performing corrective surgery for varus deformity.
Operative report detailing the procedure and indication for surgery.
Orthopedic surgeons must document the rationale for surgical intervention.
Specifying laterality is crucial as it impacts treatment decisions and reflects the precise nature of the patient's condition, ensuring accurate coding and billing.
