Unequal limb length (acquired), tibia and fibula
ICD-10 M21.76 is a billable code used to indicate a diagnosis of unequal limb length (acquired), tibia and fibula.
Unequal limb length, specifically affecting the tibia and fibula, is a condition characterized by a discrepancy in the lengths of the lower limbs due to acquired factors. This condition can arise from various causes, including trauma, surgical interventions, infections, or diseases that affect bone growth and development. For instance, a fracture that heals improperly may result in one limb being shorter than the other. Additionally, conditions such as osteomyelitis or tumors can lead to limb length discrepancies. Patients may experience functional limitations, gait abnormalities, and increased risk of joint problems due to the uneven distribution of weight and altered biomechanics. Treatment often involves corrective procedures such as limb lengthening surgeries or orthopedic interventions to address the underlying cause and restore balance. Accurate coding is essential for proper reimbursement and to ensure that the patient's condition is adequately documented for future care.
Detailed history of the injury or condition, imaging results, and treatment plans.
Post-fracture limb length discrepancies, post-surgical complications leading to unequal limb lengths.
Ensure that all relevant surgical notes and follow-up assessments are included in the documentation.
Functional assessments, therapy notes, and progress reports.
Rehabilitation following corrective surgery for limb length discrepancies.
Document the impact of the discrepancy on the patient's mobility and quality of life.
Used when performing a limb lengthening procedure.
Detailed operative report and pre-operative assessments.
Orthopedic specialists should ensure that all relevant clinical data is included.
Documentation should include a detailed history of the acquired condition, clinical findings, imaging results, and any treatment plans or surgical notes that relate to the limb length discrepancy.