The ICD-10 code for unsteady gait is used by physical therapists when characterizing gait. The term unsteadiness is defined as being liable to shake or fall and is a concern to PTs. Unsteadiness while walking results in an inefficient gait pattern and places the walker at higher risk for falls. When one feels unsteady, they are more likely to increase sedentary behaviors which can further exacerbate the underlying problems and place the person at elevated risk for developing chronic conditions like high blood pressure, diabetes, coronary artery disease and even worsen pain. When you observe a patient or client walking unsteadily, it is important to identify the cause in order to treat it effectively.
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
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.
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.
R26.81: Unsteadiness on Feet
Is it billable?
Yes, code R26.81 can be utilizedto indicate a diagnosis for billing/reimbursement purposes, however the more generic code R26 (abnormalities of gait and mobility) and R26.8 (other abnormalities of gait and mobility) are considered too-nonspecific to be used for primary billing/reimbursement purposes.
When should I use the ICD 10 code for unsteady gait?
ICD-10 codes for unsteady gait can be utilized whenever the patient or client presents with a shaky gait pattern or appears to be at higher risk for falling while walking. It is important to note that there are several other gait-specific codes that might be more appropriate to use in place of R26.81. Read on to learn about these codes.
When is an alternative code to ICD-10 code for unsteady gait more appropriate?
While unsteadiness on feet is considered a specific 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:
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.
Paralytic gait–applicable to a spastic gait pattern
Difficulty in walking, not elsewhere classified–excludes falling and unsteadiness on feet (use those specific codes instead, if applicable).
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
Unspecified abnormalities of gait and mobility–can be used generally to describe abnormal gait, nonphysiologic or functional gait disorder.
Tendency to fall, recurrent falls
History of falls, at risk for falls
Additional ICD-10 code for unsteady gait considerations
As you can see, while “unsteadiness on feet” is a billable ICD-10 code, there may be another ICD-10 code for unsteady gait that more accurately describes 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.
In addition, tools like TheraPlatform can make looking up and using codes like the ICD-10 code for unsteady gait easy when it comes to billing. Sign-up for their 30-day free trial to find out how you can simplify private practice operations like scheduling, documentation and finances.