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ICD-10 Guide
ICD-10 CodesM21.541

M21.541

Billable

Acquired clubfoot, right foot

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

Code Description

ICD-10 M21.541 is a billable code used to indicate a diagnosis of acquired clubfoot, right foot.

Key Diagnostic Point:

Acquired clubfoot, also known as talipes equinovarus, is a deformity characterized by the foot being twisted out of shape or position. In the case of acquired clubfoot, this condition develops after birth due to various factors such as trauma, neurological conditions, or other underlying health issues. The right foot is specifically affected, leading to a range of functional impairments. The foot may present with a high arch, inwardly turned heel, and toes that point downward. This condition can lead to difficulties in walking, pain, and increased risk of arthritis in later life. Treatment often involves physical therapy, bracing, or surgical intervention to correct the deformity and restore normal function. Early diagnosis and intervention are crucial for optimal outcomes, as untreated clubfoot can lead to significant mobility issues and chronic pain.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between congenital and acquired forms of clubfoot
  • Understanding the underlying causes of acquired clubfoot
  • Documenting the specific foot affected (right foot)
  • Identifying associated conditions that may complicate treatment

Audit Risk Factors

  • Inadequate documentation of the cause of the acquired clubfoot
  • Failure to specify the affected foot
  • Lack of supporting clinical evidence for the diagnosis
  • Incorrect coding of associated conditions

Specialty Focus

Medical Specialties

Orthopedics

Documentation Requirements

Detailed clinical notes on the deformity, treatment plans, and follow-up care.

Common Clinical Scenarios

Patients presenting with foot deformities, post-trauma assessments, and pre-surgical evaluations.

Billing Considerations

Ensure accurate documentation of the foot affected and any associated conditions.

Physical Therapy

Documentation Requirements

Progress notes detailing therapy sessions, patient response, and modifications to treatment plans.

Common Clinical Scenarios

Rehabilitation following corrective surgery or conservative management of clubfoot.

Billing Considerations

Document specific exercises and patient progress to support the need for ongoing therapy.

Coding Guidelines

Inclusion Criteria

Use M21.541 When
  • According to ICD
  • 10 guidelines, M21
  • 541 should be used when the condition is specifically acquired and affects the right foot
  • Documentation must clearly indicate the nature of the acquired deformity and any associated conditions

Exclusion Criteria

Do NOT use M21.541 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

28485CPT Code

Surgical correction of clubfoot

Clinical Scenario

Used when surgical intervention is performed to correct the acquired clubfoot.

Documentation Requirements

Operative reports detailing the procedure and pre-operative assessments.

Specialty Considerations

Orthopedic surgeons must provide comprehensive documentation to support the surgical necessity.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more precise coding of acquired conditions like clubfoot, improving data accuracy and facilitating better patient management.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more precise coding of acquired conditions like clubfoot, improving data accuracy and facilitating better patient management.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more precise coding of acquired conditions like clubfoot, improving data accuracy and facilitating 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 is the difference between congenital and acquired clubfoot?

Congenital clubfoot is a developmental condition present at birth, while acquired clubfoot develops later due to factors such as trauma or neurological disorders.