ICD-10 FAQ Part 4

A few months ago, we started receiving tons of questions about the switch to ICD-10. So many questions that we quickly put together our first ICD-10 FAQ post, which we thought was the best darned thing ever (hence the title). But there was no satisfying your need for speed—er, answers. In fact, your questions about the code set switch started coming in even faster (unlike the healthcare industry’s transition to ICD-10, which was the slowest thing ever). Clearly, the impending coding change had folks feeling more than a little anxious, so we compiled a second and a third FAQ post. Even now, as ICD-9 (Tokyo) drifts further and further away, we’re still receiving tons of questions. Here are the answers to your most-pressing ICD-10 questions—for now, anyway:

Where do I find information on state regulations related to ICD-10?

We suggest contacting your payers, as well as consulting your state association’s website/state practice act, to get the most up-to-date, state-specific information.

What’s the difference between R53.1, Weakness, and M62.81, Muscle weakness (generalized)?

According to this resource, M62.81 is typically classified as a disorder characterized by a reduction in the strength of muscles in multiple anatomic sites, or a reduction in the strength of muscles in multiple anatomic sites. R53.1, on the other hand, is a sign or symptom associated with:

  • weakness and diminished or absent energy and strength;
  • debility, or lack or loss of strength and energy;
  • physical weakness, lack of strength and vitality, or a lack of concentration;
  • lack of physical or mental strength;
  • liability to failure under pressure or stress or strain;
  • weakness; and/or
  • lack of energy and strength.

If I shouldn’t use unspecified codes, then why are they even an option?

The unspecified codes exist in case there truly is not another, more specific option available. However, if a more specific option is available, you absolutely should use it.

If a patient experiences muscle weakness in a specific area, should I use M62.81?

The clinical description for M62.81 reads, “A disorder characterized by a reduction in the strength of muscles in multiple anatomic sites.” Because this code describes weakness in multiple anatomic sites, it would not be appropriate for weakness that exists in a specific location. As mentioned in our other FAQs, if available, you should always code for the underlying condition causing the muscle weakness first.

Can I list a condition like poor balance as a primary diagnosis?

You should code first for the underlying condition (i.e., what’s causing the patient’s balance issues). If you can’t determine the underlying condition, ICD-10 code R26.81, Unsteadiness on feet, might be a good option.

What code should I use for difficulty walking? R26.2 or R26.89?

Depending on your evaluation, you might discover the reason behind the disordered movement is best described by one code more than the other. Each code has its own synonyms that can help you make your selection.

For example, this resource explains that the description synonyms for R26.2, difficulty walking are:

  • Difficulty walking
  • Walking disability

The description synonyms for R26.89, Other abnormalities of gait, and mobility are:

  • Cautious gait
  • Gait disorder due to weakness
  • Gait disorder, painful gait
  • Gait disorder, weakness
  • Gait disorder, postural instability
  • Gait disorder, multifactorial
  • Toe walking and toe-walking gait
  • Limping/limping child

Should I code for accidents/incidents that affected my patients in the past?

You cannot—and should not—code for what you don’t know. If you can’t say for certain that the accident/incident directly correlates to the patient’s current condition, don’t code for it.

What if I have a highly-specific clinical coding question, and I can’t find the answer?

We’re happy to answer your questions to the best of our abilities. However, if the example is extremely clinical in nature, we can’t give you a definitive answer. But, we do know of a resource exactly for these types of situations. If you are able to supply supporting documentation for your particular scenario, you can submit your coding questions via this AHA portal.

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We’re more than a month into the so-far-so-good transition, but we expect the questions to keep coming faster and furious-er (um, yeah—something like that). And that’s OK. We’ve got you covered. Fast five, anyone?