ICD 10 Coding Alert

Patients who report to the neurologist with problems related to involuntary movements, gait and mobility, or other coordination issues need your physician’s expertise to diagnose their condition and get them on the road to treatment.

• R25.0 (Abnormal head movements)
• R25.1 (Tremor, unspecified)
• R25.2 (Cramp and spasm)
• R25.3 (Fasciculation). Fasciculation occurs when a patient suffers localized muscle contractions or twitches that are visible under the skin. Fasciculations can occur anywhere, but you will see them most often in eyelids, calves, thighs, and arms.

Report R26.- Codes for Abnormalities of Gait/Mobility

When the issue at hand is affecting the patient’s gait/mobility, you’d move to the R26.- (Abnormalities of gait and mobility) code set. These codes go the 4th — or in some cases, 5th — character. Codes in this family include:

• R26.0 (Ataxic gait). Use this diagnosis code when a patient exhibits unsteady, uncoordinated walking; this could point to certain neurological conditions affecting the cerebellum or its connections in the brain. When the cerebellum or its connections are damaged or dysfunc­tional, ataxic gait can occur.
• R26.1 (Paralytic gait). Paralytic gait is also referred to as spastic gait or hemiplegic gait. Use this diagnosis code when a patient exhibits an abnormal walking pattern with weakness or paralysis on one side of the body. This is usually a product of damage to the brain or spinal cord, which affects the motor pathways responsible for controlling movement.
• R26.2 (Difficulty in walking, not elsewhere classified)
• R26.81 (Unsteadiness on feet).

Report R27.- for Ataxia, Other Coordination Issues

For any other lack of coordination diagnoses, you’ll move to R27.- (Other lack of coordination). These very general codes include one that’s a bit more specific: R27.0 (Ataxia, unspecified).

Definition: Ataxia is a neurological condition whose main symptom is loss of muscle coordination. This can lead to an unsteady gait, clumsiness, and difficulty with balance and coordination of movements. Ataxia can affect a range of everyday movements, including walking, speaking, swallowing, and fine motor skills.

Get to Know R29.- Codes for ‘Other’ Movement Issues

If none of the above ICD-10-CM code sets fulfills your needs, you’ll want to move to R29.- (Other symptoms and signs involving the nervous and musculoskeletal systems). These codes can be anywhere from four to six characters, so be careful or you won’t code correctly. Read on for an explanation of these conditions, where necessary:

• R29.0 (Tetany). Use this diagnosis code when a patient suffers involuntary muscle contractions that could bring on muscle spasms, cramps, and twitching.
• R29.1 (Meningismus). When a patient has meningismus, they are exhibiting signs and symptoms that mimic those seen in meningitis; the difference, however, is that there is no inflammation of the meninges. Essentially, you’ll use this code when a patient exhibits a collection of symptoms that suggest irritation or inflammation of the meninges, but there is no evidence of actual infection or inflammation.
• R29.2 (Abnormal reflex)
• R29.3 (Abnormal posture)
• R29.4 (Clicking hip)
• R29.5 (Transient paralysis). Use this diagnosis code when a patient suffers a temporary loss or impairment of muscle function, usually affecting one or more limbs or specific muscle groups. The impairment usually occurs suddenly and last for a short time before it resolves, either sponta­neously or with treatment.
• R29.6 (Repeated falls)
• R29.7- (National Institutes of Health Stroke Scale (NIHSS) score). You should only use this code as a secondary diagnosis for a patient that has suffered a cerebral infarction (CI).
• R29.81- (Other symptoms and signs involving the nervous system)
• R29.89- (Other symptoms and signs involving the musculoskeletal system)
• R29.9- (Unspecified symptoms and signs involving the nervous and musculoskeletal systems).

Chris Boucher, MS, CPC, Senior Development Editor, AAPC