Find comprehensive information on Limb Length Discrepancy (LLD), including clinical documentation, medical coding (ICD-10, CPT), diagnosis, treatment, and leg length inequality management. Learn about anatomical shortening, functional shortening, causes of limb length discrepancy, and how healthcare professionals approach LLD assessment and documentation for accurate billing and coding. Explore resources for patients and physicians covering limb lengthening surgery, epiphysiodesis, shoe lifts, and other treatment options.
Also known as
Congenital malformations of limb(s)
Includes congenital limb length discrepancies.
Other non-traumatic disorders of bone
May include acquired limb length discrepancies.
Dislocation of hip
Hip dislocations can contribute to leg length inequality.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the limb length discrepancy acquired?
Yes
Due to fracture malunion?
No
Is it congenital?
When to use each related code
| Description |
|---|
| Unequal leg lengths |
| Leg length inequality |
| Short stature |
Incorrect or missing laterality (right, left, bilateral) for limb length discrepancy can lead to claim denials and inaccurate data.
Lack of documentation specifying the cause (congenital, acquired) and severity of the discrepancy impacts accurate coding and reimbursement.
Missing or insufficient documentation of the precise limb length difference hinders accurate coding and may trigger audits.
Patient presents with a limb length discrepancy (LLD), also known as anisomelia, leg length inequality, or short leg syndrome. Clinical examination reveals a difference in the length of the lower extremities, confirmed by direct measurement from the anterior superior iliac spine (ASIS) to the medial malleolus. Measurements were performed in the supine position. The discrepancy is quantified as [measurement of longer leg] cm on the right/left and [measurement of shorter leg] cm on the right/left, resulting in a total discrepancy of [difference] cm. The patient reports [symptoms, e.g., gait abnormalities, back pain, hip pain, knee pain, or no symptoms]. The etiology of the LLD is [congenital, acquired, idiopathic]. Differential diagnosis includes developmental dysplasia of the hip, scoliosis, pelvic obliquity, and other neuromuscular conditions. Radiographic imaging, including a full-length standing anteroposterior radiograph of both lower extremities, including the hips and ankles (orthoroentgenogram or scanogram), is ordered/reviewed to further evaluate the discrepancy and assess bone age. Treatment options including observation, shoe lifts, epiphysiodesis, or limb lengthening surgery were discussed with the patient. The chosen treatment plan is dependent on the magnitude of the discrepancy, the patient's age, skeletal maturity, symptoms, and functional limitations. Short leg syndrome treatment, leg length inequality management, and limb length discrepancy correction were all addressed in the discussion. Follow-up appointment scheduled for [date] to reassess and monitor progress. ICD-10 code [appropriate code, e.g., M21.81, Q72.4] is assigned. CPT codes for measurements, imaging, and procedures will be assigned as appropriate.