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Home/Diagnosis/ICD-10 Coding for Gait Imbalance

ICD-10 Coding for Gait Imbalance

R26.81
R26.0
R26.1

Complete ICD-10-CM coding and documentation guide for icd-10 coding for gait imbalance includes clinical validation requirements, medical necessity guidelines, and coding policies.

Also Known as:
Unsteady Gait
Ataxic Gait
Paralytic Gait
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Key Information: ICD-10 Coding for Gait Imbalance

Essential facts and insights about ICD-10 Coding for Gait Imbalance

Use ICD-10 code R26.81 for unsteadiness on feet, ensuring proper documentation in clinical notes.

Primary ICD-10-CM Codes

Unsteadiness on feet

Billable Code
R26.81
Billable

Diagnostic Criteria

clinical:
  • • Presence of unsteady gait without specific neurological cause.
coding:
  • • Avoid using unspecified codes when specific codes are applicable.

Applicable To

  • • Unsteady gait

Important Notes

  • • Ensure to document specific clinical findings such as balance tests and muscle strength.

Ataxic gait

Billable Code
R26.0
Billable

Diagnostic Criteria

clinical:
  • • Cerebellar atrophy on MRI
  • • Abnormal finger-to-nose test

Applicable To

  • • Cerebellar ataxia

Important Notes

  • • Document cerebellar signs and imaging findings.

Paralytic gait

Billable Code
R26.1
Billable

Diagnostic Criteria

clinical:
  • • Modified Ashworth Scale ≥2
  • • H-reflex latency >30ms

Applicable To

  • • Spastic gait

Important Notes

  • • Document spasticity and related neurological findings.
Ancillary Codes

Additional codes that may be used with this diagnosis

Z91.81

History of falls

Use as a secondary code when there is a history of falls without current unsteadiness.

Frequently Asked Questions

What is the ICD-10 code for unsteady gait?

The ICD-10 code for unsteady gait is R26.81, used when unsteadiness is the primary symptom without a specific underlying cause.

When should R26.0 be used?

R26.0 should be used for ataxic gait when cerebellar signs are present, such as a wide base and heel-to-shin incoordination.

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