Find comprehensive information on Hematoma of the Leg diagnosis, including clinical documentation, medical coding, ICD-10 codes, healthcare guidelines, treatment options, and patient care resources. Learn about symptoms, causes, and differential diagnosis for leg hematoma. Explore best practices for accurate medical record documentation and appropriate coding for hematoma of lower extremity, thigh hematoma, and calf hematoma. This resource offers valuable insights for physicians, nurses, coders, and other healthcare professionals involved in the diagnosis and management of leg hematomas.
Also known as
Injuries to the leg
Covers injuries like hematomas specifically to the leg region.
Other specified soft tissue disorders
Includes hematomas not otherwise specified in other categories.
Injuries to the hip and thigh
May be relevant if the hematoma extends to the upper leg.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the hematoma traumatic?
Yes
Site specified?
No
Associated with anticoagulant?
When to use each related code
| Description |
|---|
| Leg hematoma |
| Contusion of leg |
| Muscle strain of leg |
Lack of documentation specifying the precise location (e.g., thigh, calf) leading to inaccurate coding of the hematoma of the leg.
Failure to distinguish whether the hematoma is caused by trauma for proper code assignment and accurate reflection of the etiology.
Missing documentation of depth (subcutaneous, intramuscular) and size of the hematoma, impacting proper code selection and severity reflection.
Patient presents with complaints consistent with a leg hematoma. Onset of symptoms occurred [Number] daysweeks following [Mechanism of injury; e.g., blunt trauma, contusion, fall, strain, anticoagulant therapy]. Location of hematoma is noted on the [RightLeft] [AnteriorPosteriorMedialLateral] aspect of the [ProximalMidDistal] [ThighLower leg; specify anatomical location, e.g., gastrocnemius, quadriceps]. Physical examination reveals [Size in cm] area of ecchymosis, with [Describe color: e.g., erythema, purplish discoloration, bluish discoloration]. Palpation reveals [TendernessIndurationFluctuance]. Pain is reported as [MildModerateSevere] and described as [Type of pain: e.g., throbbing, aching, sharp]. Range of motion is [LimitedNormal], with [Specific limitation if applicable]. Peripheral pulses are [PresentDiminishedAbsent] in the [Dorsalis pedisPosterior tibial] arteries. Neurological examination is grossly intact. Differential diagnosis includes muscle contusion, deep vein thrombosis, soft tissue sarcoma. Assessment: Hematoma of the [RightLeft] leg, likely secondary to [Etiology]. Plan: Conservative management with RICE (rest, ice, compression, elevation). Patient advised to avoid NSAIDs for the next 48 hours to minimize bleeding risk. Pain management with acetaminophen. Follow-up in [Number] weeks to monitor resolution of hematoma. Patient education provided regarding signs and symptoms of complications, including infection, compartment syndrome, and persistent pain. Instructions provided for activity modification and return to normal activity as tolerated. ICD-10 code: [Appropriate ICD-10 code, e.g., S80.10XA, S80.109A].