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v1.0.0
ICD-10 Guide
ICD-10 CodesR26.9

R26.9

Unspecified abnormalities of gait and mobility

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/11/2025

Code Description

ICD-10 R26.9 is a billable code used to indicate a diagnosis of unspecified abnormalities of gait and mobility.

Key Diagnostic Point:

R26.9 is used to classify unspecified abnormalities of gait and mobility, which can manifest as difficulties in walking, changes in walking patterns, or other mobility issues that do not fit into more specific categories. These abnormalities may arise from a variety of underlying conditions, including neurological disorders, musculoskeletal issues, or systemic diseases. Symptoms may include limping, shuffling, unsteadiness, or an inability to walk without assistance. The clinical context often involves a thorough assessment of the patient's history, physical examination, and possibly imaging or laboratory tests to identify the underlying cause. Given the broad nature of this code, it is essential for healthcare providers to document the patient's symptoms comprehensively to ensure accurate coding and appropriate management.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Broad range of potential underlying causes
  • Variability in clinical presentation
  • Need for comprehensive documentation
  • Potential overlap with other gait-related codes

Audit Risk Factors

  • Inadequate documentation of symptoms
  • Failure to specify underlying conditions
  • Misuse of the code when more specific codes are available
  • Inconsistent coding practices across providers

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Detailed patient history, including onset and duration of symptoms, associated conditions, and any previous treatments.

Common Clinical Scenarios

Patients presenting with unexplained mobility issues, often requiring a comprehensive evaluation for chronic diseases.

Billing Considerations

Consideration of comorbidities that may affect mobility, such as diabetes or cardiovascular conditions.

Emergency Medicine

Documentation Requirements

Acute assessment of gait abnormalities, including trauma history and immediate interventions.

Common Clinical Scenarios

Patients with sudden onset of gait abnormalities due to falls or acute neurological events.

Billing Considerations

Rapid assessment and documentation are crucial, especially in cases of potential stroke or head injury.

Coding Guidelines

Inclusion Criteria

Use R26.9 When
  • Coders should refer to the official ICD
  • CM coding guidelines, ensuring that the code is used only when no other more specific codes apply
  • Documentation must support the use of R26
  • 9, including a clear description of the patient's symptoms and any relevant clinical findings

Exclusion Criteria

Do NOT use R26.9 When
No specific exclusions found.

Related CPT Codes

99213CPT Code

Established patient office visit, Level 3

Clinical Scenario

Used when evaluating a patient with gait abnormalities in an outpatient setting.

Documentation Requirements

Document the patient's history, examination findings, and any treatment plans.

Specialty Considerations

Internal medicine providers should focus on chronic conditions affecting mobility.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more detailed coding of gait abnormalities, but R26.9 remains a broad category that requires careful documentation to avoid misclassification and ensure appropriate reimbursement.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more detailed coding of gait abnormalities, but R26.9 remains a broad category that requires careful documentation to avoid misclassification and ensure appropriate reimbursement.

Reimbursement & Billing Impact

reimbursement.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

When should I use R26.9?

Use R26.9 when a patient presents with gait or mobility abnormalities that do not fit into more specific categories. Ensure that documentation supports the use of this code.

What are common causes of gait abnormalities?

Common causes include neurological disorders, musculoskeletal conditions, and systemic diseases. A thorough evaluation is necessary to determine the underlying cause.