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R60.0
ICD-10-CM
Swollen Leg

Find comprehensive information on swollen leg diagnosis, including causes like edema, cellulitis, DVT, and lymphedema. Learn about clinical documentation requirements, medical coding guidelines for ICD-10 codes (e.g., R22.2), and differential diagnosis considerations. Explore treatment options, leg swelling symptoms, peripheral edema, venous insufficiency, and lower extremity swelling management. This resource provides valuable insights for healthcare professionals, medical coders, and patients seeking information on leg swelling diagnosis and care.

Also known as

Leg Edema
Lower Limb Swelling

Diagnosis Snapshot

Key Facts
  • Definition : Leg enlargement due to fluid buildup or inflammation.
  • Clinical Signs : Pain, redness, warmth, swelling, difficulty walking.
  • Common Settings : Deep vein thrombosis, cellulitis, injury, heart failure.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC R60.0 Coding
R60-R69

Symptoms and signs involving skin and subcutaneous tissue

Includes swelling, edema, and related skin/subcutaneous tissue symptoms.

I80-I89

Diseases of veins, lymphatic vessels and nodes, not elsewhere classified

Venous and lymphatic conditions that can cause leg swelling.

M70-M79

Soft tissue disorders

Soft tissue inflammation or injury potentially causing localized swelling.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is the swelling due to trauma?

  • Yes

    Is there a fracture?

  • No

    Is there cellulitis?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Swollen Leg
Deep Vein Thrombosis (DVT)
Cellulitis

Documentation Best Practices

Documentation Checklist
  • Swollen leg laterality (left, right, bilateral)
  • Onset and duration of swelling
  • Associated symptoms (pain, redness, warmth)
  • Physical exam findings (edema, tenderness)
  • Differential diagnosis considerations

Coding and Audit Risks

Common Risks
  • Unspecified Edema Coding

    Coding swollen leg as unspecified edema (e.g., R60.9) without documenting underlying cause leads to inaccurate severity and reimbursement.

  • Missed DVT Diagnosis

    Failing to investigate and document deep vein thrombosis (DVT) as a potential cause of leg swelling poses significant patient safety and coding risks.

  • Lacking Laterality Specificity

    Documenting swollen leg without specifying right or left leg can cause coding errors impacting data analysis and treatment plans.

Mitigation Tips

Best Practices
  • Elevate leg, compression therapy for edema ICD-10 R60.9
  • Rule out DVT, venous insufficiency via Doppler ultrasound CDI best practice
  • Accurate limb circumference measurements for lymphedema monitoring, M79.80
  • Medication reconciliation for CHF, renal disease impacting leg swelling I50.9 I12.9
  • Encourage mobility, patient education on risk factors for recurrence

Clinical Decision Support

Checklist
  • Rule out DVT: Wells score and D-dimer?
  • Unilateral swelling? Assess for cellulitis, injury.
  • Bilateral? Consider CHF, venous insufficiency, medication.
  • Document leg circumference, location, and duration.
  • Patient education: Limb elevation, compression therapy.

Reimbursement and Quality Metrics

Impact Summary
  • Swollen Leg: Coding accuracy impacts reimbursement for lymphedema, cellulitis, DVT. ICD-10 specificity crucial.
  • Hospital reporting: Swollen leg diagnosis quality metrics tied to venous thromboembolism (VTE) prophylaxis adherence.
  • Medical billing: Proper documentation of swollen leg etiology key for appropriate E M coding and claim acceptance.
  • Accurate coding and documentation improve patient outcomes and reduce healthcare costs associated with swollen legs.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes for . Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • Code underlying cause, not just swelling
  • Specify laterality: right, left, bilateral
  • Document location and characteristics of swelling
  • Consider DVT codes for suspected clots
  • Rule out systemic causes, code specifics

Documentation Templates

Patient presents with a complaint of leg swelling, also described as lower extremity edema or limb swelling.  Onset of swelling was [duration and onset details, e.g., gradual over the past week, sudden onset this morning].  Location of swelling is [specific location, e.g., right calf, left ankle, entire left leg].  Patient describes the swelling as [character of swelling, e.g., pitting, non-pitting, painful, painless, tight, warm, red].  Associated symptoms include [list associated symptoms, e.g., pain, redness, warmth, shortness of breath, chest pain, immobility, ulceration, discoloration].  Patient denies [list pertinent negatives, e.g., trauma, recent surgery, fever, chills, recent travel].  Medical history includes [list relevant medical history, e.g., hypertension, diabetes, heart failure, deep vein thrombosis, cellulitis, lymphedema, venous insufficiency].  Current medications include [list current medications].  Physical exam reveals [objective findings, e.g.,  2+ pitting edema of the right lower extremity extending from the ankle to the mid-calf, palpable warmth, erythema, tenderness to palpation, positive Homan's sign if applicable,  peripheral pulses present and palpable].  Differential diagnosis includes [list differential diagnoses, e.g., deep vein thrombosis, cellulitis, venous insufficiency, lymphedema, heart failure, kidney disease, medication side effect].  Ordered [diagnostic tests ordered, e.g., venous Doppler ultrasound, D-dimer, complete blood count, basic metabolic panel].  Plan includes [treatment plan, e.g., elevation of the affected limb, compression therapy, medications such as diuretics or anticoagulants if indicated, referral to specialist if necessary, patient education regarding signs and symptoms of worsening condition].  Return for follow-up in [timeframe] to assess response to treatment.