ICD-10 Coding for Gait Ataxia(R26.0, G11.9)
Complete ICD-10-CM coding and documentation guide for Gait Ataxia. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Gait Ataxia
R26.0-R26.9Primary Range
Abnormalities of gait and mobility
This range includes codes for various gait abnormalities, with R26.0 specifically for ataxic gait.
Hereditary ataxia
This range includes codes for hereditary ataxias, which may present with gait ataxia.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R26.0 | Ataxic gait | Use when cerebellar dysfunction is confirmed with clinical findings and SARA score. |
|
| G11.9 | Hereditary ataxia, unspecified | Use when hereditary ataxia is confirmed but specific type is not identified. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for gait ataxia
Essential facts and insights about Gait Ataxia
Primary ICD-10-CM Codes for gait ataxia
Decision Criteria
clinical Criteria
- Presence of cerebellar signs and SARA score ≥4
Applicable To
- Cerebellar ataxia
Excludes
- Unsteadiness on feet (R26.81)
Clinical Validation Requirements
- Wide-based stance (>10 cm between heels)
- SARA gait subscore ≥4
- Positive Romberg test with eyes open
Code-Specific Risks
- Misclassification with general unsteadiness codes
Coding Notes
- Ensure documentation supports cerebellar origin to avoid misclassification.
G11.9 - Hereditary ataxia, unspecified
Use when hereditary ataxia is confirmed but specific type is not identified.
Applicable To
- Spinocerebellar ataxia
Clinical Validation Requirements
- Genetic testing confirming hereditary ataxia
- Family history of ataxia
Coding Notes
Sequence hereditary ataxia codes before R26.0.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Gait Ataxia to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R26.0.
Impact
Clinical: Inaccurate diagnosis, Regulatory: Non-compliance with coding standards, Financial: Potential reimbursement issues
Mitigation Strategy
Use specific terms like 'ataxic gait', Include objective measurements
Impact
Reimbursement: Potential underpayment due to less specific coding, Compliance: Non-compliance with coding guidelines, Data Quality: Inaccurate clinical data representation
Mitigation Strategy
Ensure clinical documentation specifies cerebellar involvement.
Impact
Misclassification of gait disturbances
Mitigation Strategy
Ensure detailed clinical documentation supports the specific code used.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Gait Ataxia, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Gait Ataxia
Use these documentation templates to ensure complete and accurate documentation for Gait Ataxia. These templates include all required elements for proper coding and billing.
Cerebellar Ataxia with Gait Disturbance
Specialty: NeurologyRequired Elements
- Wide-based stance
- SARA score
- MRI findings
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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