Unable to balance when standing with both feet apart. Unable to balance when standing with both feet in semi tandem stance. Unable to balance when standing with both feet in tandem stance. Unable to balance when standing with both feet together. Unsteadiness present. Unsteady when standing.
R26.81 is a billable diagnosis code used to specify a medical diagnosis of unsteadiness on feet. The code R26.81 is valid during the fiscal year 2021 from October 01, 2020 through September 30, 2021 for the submission of HIPAA-covered transactions.
To make a diagnosis, your health care provider will ask about your medical history and do a physical exam. This will include checking your bones and muscles and doing a neurological exam. In some cases, you may have other tests, such as lab or imaging tests.
R26.89 is a billable diagnosis code used to specify a medical diagnosis of other abnormalities of gait and mobility. The code R26.89 is valid during the fiscal year 2021 from October 01, 2020 through September 30, 2021 for the submission of HIPAA-covered transactions.
To make a diagnosis, your health care provider will ask about your medical history and do a physical exam. This will include checking your bones and muscles and doing a neurological exam. In some cases, you may have other tests, such as lab or imaging tests.
A green check mark by the code indicates that the code is complete and billable. It’s up to you and your clinical judgement to determine if that code is the one that best describes the patient’s condition. I deleted a patient’s ICD-9 code, and I want to add it back to the patient’s chart.
If the condition that caused the patient to undergo surgery no longer exists, then you should not code for it. Instead, you can submit any applicable pain/symptom codes relevant to the patient’s treatment. Ultimately, the codes you use, and the order in which you submit them, are up to you and your clinical judgment. Just make sure your documentation clearly supports your coding choices.
You cannot code for what you don’t know. So, if you don’t know what caused the patient’s injury—or if there’s no definitive correlation between a known causal event and the patient’s current condition—then don’t code for it. Remember, external cause codes (like those that denote accidents) are optional. Just make sure you accurately record any potentially relevant information within the patient’s documentation.
While there is not an aftercare code for every single surgery, in many cases, the proper way to designate the phase of treatment (i.e., indicate that the patient is receiving aftercare) is to code for the original acute injury and add the appropriate seventh character (which in this case, would be D).
Yes, M54.5 is a complete, billable code, and thus, you can use it as the primary. However, because it’s not a very specific code, you should only use it as the patient’s primary diagnosis code if there’s not a more specific code available to accurately describe the patient’s condition.