While we often think about impairments like pain or muscle weakness when we are selecting ICD 10 codes, in some cases impairments of gait may warrant their own codes. Addressing function is a core tenet of modern physical therapy and while not all of your patients will be ambulatory, when walking is affected it is appropriate to include a gait-specific ICD 10 code. As we will explore below, there are a number of ICD 10 codes available that describe different characteristics of gait. Sometimes, however, the impairments of gait that you are observing do not have their own ICD 10 code. In this case, the difficulty in walking ICD 10 code may be just what you need.
Difficulty in walking can have many different causes.
Here are some of the underlying causes you may identify in your patients:
- Muscular deconditioning and disuse atrophy after illness, injury or immobilization
- Neuromuscular disease
- Neurologic injury or illness
- Functional Neurological Disorder
- Poor balance
- Muscle weakness
- Impaired joint or muscle flexibility or range of motion
- Impaired coordination
- Low vision
According to the Centers for Disease Control and Prevention (CDC), 1 in 7 adults experience a mobility-related disability. They describe this further to mean that on average 14% of adults experience serious difficulty walking or climbing stairs. This number likely rises considerably if you include those with mild to moderate mobility impairments. For ambulatory individuals, difficulty walking can significantly impact their ability to participate in activities of daily living, care for their children, perform mobility-related work duties and participate in exercise and leisure activities.
Since you have the ability to positively affect these impairments, understanding how to correctly utilize the difficulty in walking ICD-10 code is imperative for minimizing insurance claim denials. If you, like many therapists, have some experience searching for and selecting difficulty in walking 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 difficulty in walking ICD-10 code in more detail.
An introduction to low back pain ICD 10 codes
All HIPAA-covered entities are required to submit ICD-10 codes if seeking reimbursement for services from an insurance company. This includes physical therapists.
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).
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.
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.
When selecting difficulty in walking ICD-10 codes, 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, R26.2.
R26.2: Difficulty in walking, not elsewhere classified
Is it billable? Yes, code R26.2 can be utilized to indicate a diagnosis for billing/reimbursement purposes, however the more generic code R26 (abnormalities of gait and mobility) is considered too-nonspecific to be used for primary billing/reimbursement purposes.
When should I use this code?
Difficulty in walking, not elsewhere classified is a code that can be utilized to indicate impairments in walking or disability in walking. This code specifies it is to be used to indicate difficulties in walking that cannot be described (i.ee., classified) more accurately by other available ICD 10 codes. For example, if the patient presents with gait ataxia then you would use the code R26.0–Ataxic gait–rather than R26.2.
Read below to learn about additional gait-specific codes that may be more appropriate to your case. Remember, the difficulty in walking ICD-10 code, not elsewhere classified, is intended to be utilized only when there is not a more specific alternative available.
When is an alternative difficulty in walking ICD-10 code more appropriate?
While the difficulty in walking ICD-10 code is considered a billable code, there are times when other codes may more accurately describe the type of gait you are seeing.
If this is the case, use one of the following codes:
- R26.0: Ataxic gait: Applicable to a stumbling, uncoordinated gait pattern. Characterized by difficulty coordinating movements for normal walking, often associated with impairments in motor and sensory function. May be associated with conditions of the central nervous system such as cerebellar or basal ganglia disorders, spinal cord disorders or of the peripheral nervous system like peripheral neuropathy.
- R26.1: Paralytic gait: Applicable to a spastic gait pattern
- R26.81: Unsteadiness on feet: Applicable to a gait pattern that appears unsteady or have poor balance when walking
- R26.89: Other abnormalities of gait and mobility: This code can be used to describe many types of gait that would not otherwise be covered by the previous codes listed.
- Cautious gait
- Gait disorder due to weakness
- Gait disorder, multifactorial
- Gait disorder, painful gait
- Gait disorder, postural instability
- Gait disorder, weakness
- Gait disturbance, senile
- Limp in childhood
- Limp occurring during childhood
- Limping child
- Multifactorial gait problem
- Painful gait
- Toe walking
- Toe-walking gait
- R26.9: Unspecified abnormalities of gait and mobility–can be used generally to describe abnormal gait, nonphysiologic or functional gait disorder.
Additional code considerations
As you can see, while “difficulty in walking, not elsewhere classified” is a billable ICD-10 code, there may be other codes that more accurately describe the gait that you are observing that you would want to utilize instead.
Stay up to date: The Centers for Medicare and Medicaid Services publish an updated list of codes each year to go into effect October 1 and remain in effect until September 30 of the following year. Sites like ICD10 Data can also be helpful in identifying code changes once they update their list as announced on their homepage.
When using the difficulty in walking ICD 10 code or other ICD-10 codes for your physical therapy private practice, an EHR and practice management tool like TheraPlatform can make it easier. They also offer a free, 30-day trial. No credit card required. Cancel anytime.
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