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2025 ICD-10-CM code L03.116

Cellulitis of the left lower limb.

Appropriate documentation is essential for accurate coding.Specify the laterality (left or right) whenever possible.Additional codes might be required for the causative organism and any complications.

Modifiers may be applied depending on the circumstances of the encounter and the services rendered.For example, modifiers may be used to indicate the location of the service or to specify the type of service provided.

Medical necessity for L03.116 is established based on the presence of clinical findings consistent with cellulitis (erythema, swelling, warmth, pain).The severity of the infection, the patient’s risk factors (e.g., diabetes, immunocompromised status), and the potential for complications warrant treatment.The choice of antibiotics must be appropriate for the suspected or confirmed pathogen.

The clinical responsibility for managing a patient with L03.116 (cellulitis of the left lower limb) involves a thorough clinical evaluation including a detailed history, physical examination, and potentially diagnostic tests. This may necessitate prescribing antibiotics, managing pain and inflammation, and considering wound care if there is a break in the skin.Regular monitoring is critical to ensure successful treatment and prevent complications. The physician's role includes determining the need for hospitalization if the infection is severe or the patient is immunocompromised.

IMPORTANT:L03.115 (Cellulitis of right lower limb) is used for cellulitis in the right lower limb.Other codes may be needed depending on the specific location (e.g., toes, fingers) or causative agent.

In simple words: This code means the person has a skin infection (cellulitis) in their left leg, from the thigh down to the foot.

This code, L03.116, specifically identifies cellulitis affecting the left lower limb.It encompasses the entire left lower extremity, including the thigh, leg, ankle, and foot.Additional codes may be necessary to specify the causative organism (e.g., bacterial, fungal, etc.).

Example 1: A 65-year-old male presents with erythema, swelling, and tenderness in his left calf.He has a history of diabetes. The physician diagnoses cellulitis of the left lower limb (L03.116) and prescribes antibiotics., A 30-year-old female with a minor laceration on her left ankle develops cellulitis (L03.116).The physician cleans the wound, prescribes antibiotics, and advises on wound care., An 80-year-old patient with a history of heart failure is admitted to the hospital with severe cellulitis (L03.116) of the left leg.Intravenous antibiotics and supportive care are needed.The case is complex due to the patient's comorbidity.

Detailed history of present illness, including the onset, duration, and progression of symptoms (pain, swelling, redness, warmth).Physical examination findings documenting the extent of cellulitis and any other associated findings. Results of any diagnostic tests such as blood cultures or wound cultures, as appropriate.Details of the treatment plan, including the type and dosage of antibiotics administered, and the duration of treatment.Patient’s response to treatment should be documented.

** This code is for cellulitis affecting the left lower limb only.If cellulitis affects the entire leg, L03.11 is the appropriate code.

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