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ICD-10 Guide
ICD-10 CodesM21.962

M21.962

Billable

Unspecified acquired deformity of left lower leg

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

Code Description

ICD-10 M21.962 is a billable code used to indicate a diagnosis of unspecified acquired deformity of left lower leg.

Key Diagnostic Point:

The ICD-10 code M21.962 refers to an unspecified acquired deformity of the left lower leg. Acquired deformities can arise from various causes, including trauma, infections, or conditions such as arthritis that lead to structural changes in the bones and soft tissues. These deformities may manifest as malalignment, abnormal curvature, or changes in the shape of the leg, which can affect mobility and overall function. Common examples include bowing of the leg, shortening, or angular deformities. The left lower leg specifically refers to the area from the knee to the ankle, and deformities in this region can significantly impact gait and weight-bearing activities. Treatment often involves physical therapy, orthotic devices, or surgical interventions aimed at correcting the deformity and restoring function. Accurate coding is essential for appropriate management and reimbursement, as it reflects the complexity of the patient's condition and the interventions required.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in documentation of acquired deformities
  • Need for specificity in the underlying cause of the deformity
  • Potential for overlapping symptoms with other conditions
  • Variations in treatment approaches and their documentation

Audit Risk Factors

  • Insufficient documentation of the deformity's cause
  • Lack of detailed clinical notes regarding treatment plans
  • Inconsistent coding practices among providers
  • Failure to document the impact on function or mobility

Specialty Focus

Medical Specialties

Orthopedics

Documentation Requirements

Detailed clinical notes describing the deformity, its cause, and treatment plan.

Common Clinical Scenarios

Patients presenting with post-traumatic deformities, degenerative changes, or post-surgical complications.

Billing Considerations

Ensure that all relevant imaging and diagnostic tests are documented to support the diagnosis.

Physical Medicine and Rehabilitation

Documentation Requirements

Comprehensive assessments of functional limitations and treatment goals.

Common Clinical Scenarios

Patients requiring rehabilitation after corrective surgery or those with chronic deformities affecting mobility.

Billing Considerations

Focus on functional outcomes and the impact of the deformity on daily activities.

Coding Guidelines

Inclusion Criteria

Use M21.962 When
  • According to ICD
  • 10 guidelines, M21
  • 962 should be used when the specific cause of the acquired deformity is not documented
  • Coders should ensure that the documentation supports the use of this unspecified code and consider more specific codes if available

Exclusion Criteria

Do NOT use M21.962 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

27500CPT Code

Osteotomy, tibia, for deformity

Clinical Scenario

Used when surgical correction of the deformity is performed.

Documentation Requirements

Operative reports detailing the procedure and indication for surgery.

Specialty Considerations

Orthopedic surgeons should provide clear documentation of the deformity and surgical rationale.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of acquired deformities, improving the granularity of data for treatment and outcomes. M21.962 reflects the need for coders to be diligent in documenting the specifics of the deformity to avoid unspecified coding.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of acquired deformities, improving the granularity of data for treatment and outcomes. M21.962 reflects the need for coders to be diligent in documenting the specifics of the deformity to avoid unspecified coding.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of acquired deformities, improving the granularity of data for treatment and outcomes. M21.962 reflects the need for coders to be diligent in documenting the specifics of the deformity to avoid unspecified coding.

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 I document to support the use of M21.962?

Document the specific nature of the deformity, its cause, any treatments attempted, and the impact on the patient's function. Include imaging studies and clinical assessments.