Find information on lower extremity swelling diagnosis, including edema, lymphedema, cellulitis, DVT, venous insufficiency, and heart failure. Learn about clinical documentation requirements, ICD-10 codes (e.g., R22.2, I89.1, L03.11), medical coding best practices, and differential diagnosis for leg swelling, ankle swelling, and foot swelling. This resource provides healthcare professionals with essential insights for accurate diagnosis and coding of lower extremity swelling.
Also known as
Symptoms and signs involving skin and subcutaneous tissue
Includes localized swelling, edema, and related symptoms in the skin and subcutaneous tissues.
Noninfective disorders of lymphatic vessels and lymph nodes
Covers lymphedema and other lymphatic disorders that can cause lower extremity swelling.
Diseases of arteries, arterioles and capillaries
Peripheral vascular disease can cause swelling due to impaired blood flow.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the swelling due to trauma?
When to use each related code
| Description |
|---|
| Swelling of lower extremity |
| Venous insufficiency |
| Lymphedema |
Coding unspecified edema or swelling without documenting the underlying cause risks lower reimbursement and audit scrutiny. Specificity is crucial for accurate coding.
Failing to document the affected extremity (right, left, bilateral) leads to coding errors and impacts quality reporting and reimbursement. Clearly specify laterality.
Overlooking contributing conditions like CHF, DVT, or lymphedema impacts accurate severity capture (e.g., MCC/CC) and risk adjustment. Document all relevant diagnoses.
Patient presents with complaints of lower extremity swelling, also described as leg swelling or edema. Onset of swelling is reported as [onset duration - e.g., gradual over several weeks, acute onset this morning]. Location of swelling is noted in the [specific location - e.g., right ankle, bilateral feet, left calf] and is characterized as [characterization - e.g., pitting, non-pitting, soft, firm, tender, non-tender]. Patient reports [associated symptoms - e.g., pain, redness, warmth, shortness of breath, chest pain, immobility, recent surgery, recent travel, trauma]. Medical history includes [relevant medical history - e.g., hypertension, diabetes, heart failure, venous insufficiency, deep vein thrombosis, cellulitis, lymphedema, kidney disease, liver disease, medication use including diuretics and antihypertensives]. Physical exam reveals [objective findings - e.g., palpable pulses, skin discoloration, increased skin temperature, ulcerations, varicose veins, range of motion limitations]. Differential diagnosis includes venous insufficiency, deep vein thrombosis, cellulitis, lymphedema, heart failure, kidney disease, liver disease, and medication side effects. Ordered [diagnostic tests - e.g., venous Doppler ultrasound, D-dimer, complete blood count, basic metabolic panel, liver function tests]. Preliminary assessment suggests [likely diagnosis - e.g., possible venous insufficiency, rule out deep vein thrombosis]. Plan includes [treatment plan - e.g., leg elevation, compression stockings, medication adjustment, referral to specialist such as vascular surgeon, cardiologist, or nephrologist, further investigation with additional testing]. Patient education provided regarding [education topics - e.g., importance of follow-up, signs and symptoms of complications, medication management]. Return visit scheduled for [follow-up duration].