Neurology & Pain Management Coding Alert

Question: How should I code generalized weakness if the neurologist has documented no other symptoms?

Utah Subscriber

Answer: Generally, you should report 780.79 (Other malaise and fatigue) in the absence of more specific symptoms. Code 780.79 includes the following possible definitions in ICD-9:

- asthenia: any weakness, lack of strength or loss of energy, especially neuromuscular

- lethargy: listlessness, drowsiness, stupor and apathy

- postviral (asthenic) syndrome: listlessness, drowsiness, stupor and apathy; follows acute viral infection

- tiredness: general exhaustion or fatigue.

Double-check: Does the documentation only indicate weakness, with or without the term generalized, or does it indicate a more specific type of weakness? Depending on the documentation, you also should consider 728.87 (Muscle weakness [generalized]) or possibly 728.2 (Muscular wasting and disuse atrophy, not elsewhere classified) to more accurately report the condition.