Learn about left lower extremity cellulitis diagnosis, including clinical documentation, ICD-10 codes (L03.111, L03.112, L03.113, L03.119), symptoms, treatment, and healthcare best practices. This resource provides information for physicians, nurses, and medical coders on accurately documenting and coding lower limb cellulitis in medical records. Find guidance on differentiating left leg cellulitis from other conditions and ensuring proper medical coding for reimbursement.
Also known as
Cellulitis of lower leg
Bacterial skin infection of the lower leg.
Other disorders of arteries and arterioles
Circulatory problems that can predispose to cellulitis.
Diabetes mellitus
Diabetes can increase risk of infections like cellulitis.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the cellulitis of the left lower leg?
Yes
Is there lymphangitis?
No
Is it the left foot?
When to use each related code
| Description |
|---|
| Left Lower Extremity Cellulitis |
| Left Lower Extremity Erysipelas |
| Left Lower Extremity Abscess |
Coding LLE cellulitis without specifying left side can lead to inaccurate reimbursement and data analysis. Use L95.902.
Coding cellulitis without adequate clinical documentation supporting the diagnosis may cause audit issues and denials. CDI crucial.
Generalized cellulitis coding (L03.9) when a specific site (e.g., leg) is known lacks detail, impacting quality metrics and payment.
Patient presents with signs and symptoms consistent with left lower extremity cellulitis. Onset of symptoms began approximately [number] days ago and is characterized by localized erythema, edema, warmth, and tenderness to palpation involving the [specific location, e.g., left lower leg, left foot, dorsal left foot] extending from [landmark] to [landmark]. The patient reports [pain level, e.g., mild, moderate, severe] pain in the affected area, described as [pain characteristic, e.g., throbbing, aching, burning]. No fluctuance, crepitus, or purulent drainage noted. Patient denies any history of trauma, insect bites, or open wounds to the affected area. Vital signs include a temperature of [temperature], heart rate of [heart rate], blood pressure of [blood pressure], respiratory rate of [respiratory rate], and oxygen saturation of [oxygen saturation] on room air. Peripheral pulses in the left lower extremity are palpable and strong. No lymphadenopathy noted in the inguinal region. Based on clinical findings, the diagnosis of left lower extremity cellulitis is made. Differential diagnoses considered include deep vein thrombosis and contact dermatitis. Treatment plan includes [antibiotic name and dosage] for [duration] and elevation of the affected extremity. Patient education provided regarding signs and symptoms of worsening infection, and the importance of medication adherence and follow-up care. Patient instructed to return for reevaluation in [timeframe] or sooner if symptoms worsen. ICD-10 code L03.115, Cellulitis of left lower leg, is assigned. CPT codes for evaluation and management will be determined based on the complexity of the visit.