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Reader Questions:

Stay in Step With 781.2 Rules

Published on Thu Aug 25, 2005 Print Friendly and PDF PDF

Question: We are having a discussion in our office regarding the use of ICD-9 code 781.2 (Abnormality of gait). Is it true that you can use 781.2 only for neuro or ortho diagnoses?

Answer: You can use abnormality of gait in any of these situations:
 

  • the patient's gait is compromised by a neurological problem;
     
  • the patient has received corrective treatment for an orthopedic condition; or
     
  • the patient has had an amputation.

    Remember: You needn't limit 781.2 to lower extremity issues. A normal gait includes swinging the arms, so you could use this code for an upper extremity problem in limited circumstances. For example, an amputation of an arm could cause some gait difficulties that may require adaptation. Keep in mind that minor injuries, such as a fracture of the arm, would require therapy only if the patient had other issues with balance and coordination. Abnormality of gait is also listed on the OT Medical Policy on Palmetto GBA's Web site as a code that justifies occupational therapy.

    Warning: You should not use abnormality of gait for a chronic condition of the bone or joint, such as arthritis. To use 781.2 in these instances is upcoding.

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