Find information on leg swelling unspecified, including causes, diagnosis, and treatment. Learn about edema, lower extremity swelling, peripheral edema, and fluid retention in legs. This resource covers clinical documentation, ICD-10 codes for leg swelling (R60.0, R60.9), medical coding guidelines, and differential diagnosis considerations for healthcare professionals. Explore leg swelling symptoms, signs, and when to seek medical advice for unexplained leg swelling.
Also known as
Symptoms and signs involving skin and subcutaneous tissue
Includes nonspecific swelling localized to limbs, fitting leg swelling unspecified.
Venous insufficiency (chronic) (peripheral)
Venous issues often cause leg swelling, but require specific diagnosis.
Congestive heart failure
Heart failure can cause systemic edema including the legs, but requires further investigation.
Localized swelling, mass and lump
A broader category encompassing various causes of localized swelling, including in the legs.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the swelling due to a known circulatory issue?
Yes
Is it due to venous insufficiency?
No
Is it due to trauma or injury?
When to use each related code
Description |
---|
Leg swelling, unknown cause |
Venous insufficiency |
Lymphedema |
Coding Leg Swelling Unspecified (R60.9) lacks specificity, impacting reimbursement and quality metrics. CDI can clarify the underlying cause.
Generalized edema or specific causes like heart failure may be overlooked. Accurate coding ensures appropriate severity reflection.
Leg swelling can indicate DVT. Failing to investigate and code DVT when present poses a serious patient safety and medico-legal risk.
Patient presents with complaints of leg swelling, unspecified location and etiology. Presenting symptoms include edema in the lower extremity, with onset reported as (duration). Patient describes the swelling as (character: e.g., pitting, non-pitting, painful, painless, constant, intermittent). Associated symptoms may include pain, redness, warmth, tenderness, skin changes, limited range of motion, or difficulty walking. Patient denies any recent trauma, surgery, or prolonged immobility to the affected leg. Medical history includes (list relevant medical conditions such as heart failure, kidney disease, venous insufficiency, deep vein thrombosis, lymphedema, cellulitis, or medication use). Physical examination reveals (objective findings: e.g., location and extent of swelling, skin temperature and color, presence of tenderness or palpable cords, pulses, capillary refill). Differential diagnosis includes venous insufficiency, deep vein thrombosis, lymphedema, cellulitis, heart failure, kidney disease, medication side effects, and other causes of lower extremity edema. Further investigation may be warranted to determine the underlying cause of the leg swelling. Plan includes (diagnostic tests such as venous Doppler ultrasound, D-dimer, blood tests for kidney function and cardiac markers) and initial management with (treatment options like leg elevation, compression therapy, or medication depending on suspected etiology). Patient education provided on signs and symptoms of deep vein thrombosis, importance of follow-up, and self-care measures for leg swelling. Return to clinic scheduled in ( timeframe) for reevaluation and discussion of further management based on diagnostic results.