ICD-10 code for unsteady gait

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The ICD-10 code for unsteady gait is used by physical therapists for billing when noting unsteadiness while walking results in an inefficient gait pattern and places the walker at higher risk for falls.

Some common causes of unsteady gait are:

• Muscular deconditioning and disuse atrophy after illness, injury or immobilization
• Neuromuscular disease
• Neurologic injury or illness
• Functional Neurological Disorder
• Poor balance
• Muscle weakness
• Impaired coordination
• Low vision
• Dizziness

Because of its prevalence, you will likely encounter this condition frequently in your practice and understanding how to correctly utilize the ICD-10 code for unsteady gait is imperative for minimizing insurance claim denials. If you, like many therapists, have some experience searching for and selecting ICD-10 codes but don’t have a good understanding of the who, what, when and why these codes are used, see the next section for an ICD-10 code primer. Following this introduction we will discuss the ICD-10 code for unsteady gait in more detail.

An introduction to ICD-10 Codes

Who: All HIPAA-covered entities are required to submit ICD-10 codes if seeking reimbursement for services from an insurance company. This includes physical therapists.

What: The International Classification of Disease, 10th Revision (ICD-10) is a set of diagnosis, symptom, and procedure codes that physical therapists use daily in their practice. In 2015 physical therapists and all other HIPAA-covered healthcare providers transitioned from the ICD-9 to the current version, ICD-10. ICD-10 codes are alphanumeric codes. They begin with a letter and are always between three and seven characters with a decimal point placed after the third character.

The more characters it has, the more specific it is. Each code follows the following structure:

• Characters 1-3 indicate the category of the diagnosis
• Characters 4-6 indicate etiology, anatomic site, severity or other clinical detail
• Character 7 is an extension value, for example:
  • A: initial encounter (anything related to care of the initial injury)
  • D: subsequent encounter (anything related to the phase of routine care of the injury while the patient recovers–this usually refers to rehabilitation)
  • S: sequela (other conditions that may result from the presence of the primary condition)

Note, for fracture care, there are several more extensions (example: P, G, K, which signify malunion, delayed healing, or nonunion for a subsequent encounter)

When: ICD-10 codes must be submitted with relevant documentation whenever reimbursement is sought for covered services either by the healthcare entity itself or by a patient.

Why: While it may seem like an extra step in an already detailed process of documentation and billing, ICD-10 codes are required for a specific reason. Not only do they identify a medical diagnosis, but perhaps more importantly, they help insurance companies understand why the care you are providing is medically necessary and therefore, reimbursable.

Unsteadiness on Feet ICD-10: R26.81

When selecting the ICD-10 code for unsteady gait, the code with the highest number of applicable characters should be chosen, at least on the first visit. In this case, R26 is the parent code. R26 is the code for “Abnormalities of gait and mobility.” This particular code is not considered specific enough to be billable which is why we must look for the more specific codes. These codes include additional digits which provide further information about the patient’s gait. One example is the code we are focusing on today, R26.81.