leg length inequality

tag60

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Pt states he has left leg about 5" shorter than right secondary to childhood issue.

Diagnosis: Leg length inequality (finding) M21.70. Referral made. (No further information or exam done of leg.)

I'm wondering if I can code more specifically than the code shown above, M21.70, Unequal limb length (acquired), unspecified site.

More specific codes (M21.76x) indicate tibia/fibula, but that information is not specified in the record. Yet I do know it's the left leg...

How would you code this?

Thank you!!
 

CodingKing

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You would have to get the doctor to make an addendum to the medical record with more information. Unspecified means you cant use a specific code (femur vs tib vs fib).
 
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