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Wiki leg length inequality

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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!!
 
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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