Flat foot [pes planus] (acquired), right foot
ICD-10 M21.41 is a billable code used to indicate a diagnosis of flat foot [pes planus] (acquired), right foot.
Acquired flat foot, or pes planus, is a condition characterized by the collapse of the medial longitudinal arch of the foot, leading to a flat appearance. This condition can develop due to various factors including injury, obesity, aging, or conditions such as rheumatoid arthritis. In adults, acquired flat foot often results from the dysfunction of the posterior tibial tendon, which plays a crucial role in maintaining the arch. Symptoms may include pain in the foot, ankle, and lower leg, as well as difficulty in walking or standing for prolonged periods. Diagnosis typically involves a physical examination and may include imaging studies to assess the structure of the foot and rule out other conditions. Treatment options vary from conservative measures such as orthotics and physical therapy to surgical interventions aimed at restoring the arch and alleviating pain. The right foot is specifically noted in this code, indicating the need for precise documentation of the affected limb.
Detailed history of symptoms, physical examination findings, and imaging results.
Patients presenting with foot pain, difficulty walking, or previous foot injuries.
Ensure documentation reflects the acquired nature and any contributing factors.
Comprehensive assessment including functional limitations and treatment history.
Patients with chronic foot pain or those requiring surgical intervention.
Document any surgical procedures performed and their outcomes.
Used in surgical correction of acquired flat foot.
Pre-operative assessment, surgical notes, and post-operative follow-up.
Podiatrists and orthopedic surgeons must document the rationale for surgery.
Common causes include injury to the foot or ankle, obesity, aging, and conditions like rheumatoid arthritis that weaken the supportive structures of the foot.
