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
Symptoms and signs involving skin and subcutaneous tissue
Includes swelling, edema, and related skin/subcutaneous tissue symptoms.
Diseases of veins, lymphatic vessels and nodes, not elsewhere classified
Venous and lymphatic conditions that can cause leg swelling.
Soft tissue disorders
Soft tissue inflammation or injury potentially causing localized swelling.
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?
When to use each related code
Description |
---|
Swollen Leg |
Deep Vein Thrombosis (DVT) |
Cellulitis |
Coding swollen leg as unspecified edema (e.g., R60.9) without documenting underlying cause leads to inaccurate severity and reimbursement.
Failing to investigate and document deep vein thrombosis (DVT) as a potential cause of leg swelling poses significant patient safety and coding risks.
Documenting swollen leg without specifying right or left leg can cause coding errors impacting data analysis and treatment plans.
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.