OASIS Alert

Q: I was told you could only code for "Abnormality of Gait" for a patient who has undergone a procedure (TKA, THA). Could you please clarify this for me?

A: Use code 781.2 (Abnormality of gait) if the problem with gait results from an acute condition - something that occurred recently leaving the patient with a gait problem requiring physical therapy to provide gait training, says coding consultant Lynda Dilts-Benson with Reingruber & Co. in St. Petersburg, FL.
 
Some examples include: a CVA; surgery; a new foot wound; an immobilization device that requires the patient  to move in a different way so as to require gait training with an assistive device such as crutches.
 
781.2 also is used when the episode focuses on gait problems resulting from neurological conditions, such as Parkinson's or multiple sclerosis.
 
On the other hand, you would code 719.7 (Difficulty in walking) if the gait problem is due to a chronic condition such as arthritis, degenerative joint disease, muscle weakness etc., where there has not been any other intervention such as surgery or manipulation, Dilts-Benson advises. 
 
Caution: Make sure your clinicians understand the difference between these codes. 719.7 does not have case mix impact while 781.2 does, and intermediaries may give extra scrutiny to any code affecting case mix. Remember that the physician's documentation must support all diagnoses, and you should clarify with the doctor or staff if you have any questions, Dilts-Benson cautions.