Using the ICD-10 Code for Unsteady Gait

The most important thing a rehab therapist can do for a patient is to help them get back to their normal life and the things they do every day. For many patients, the ability to move about confidently in their homes and public is the key to allowing them to participate in their lives without fear of falling. That’s why gait training is such an important part of the rehab therapy toolbox. But, as with all conditions and exercises, you must choose the right ICD-10 diagnosis codes to avoid any hangups with payers. So, without further ado, here’s what you need to know about unsteady gait and other gait disorders—including the ICD-10 code for unsteady gait and related conditions. 

What is unsteady gait?

As the name suggests, an unsteady gait is one in which a patient is walking in a manner that is uncoordinated or abnormal from their standard movement, including shuffling their feet, and is unsteady and lacking balance. Generally, there are several potential causes of abnormal gait, some of which are: 

• Arthritis in the legs, hips, or feet;
• Myositisis, or inflammation and swelling of muscles;
• Tendonitis, or inflammation or swelling of tendons; 
• Diseases of the brain, spinal cord, and peripheral nerves; and
• Vision and inner ear problems.

While unsteady gait may broadly cover a patient’s symptoms, there are several gait abnormalities that might fall under that definition, courtesy of the Cleveland Clinic:

• Ataxic gait, which is described as “clumsy, staggering movements with a wide-based gait” in which a patient may “swagger back and forth and from side to side, known as titubation” while standing still. 
• Shuffling gait, where a patient may walk by dragging their feet or not bringing their feet entirely off the ground, possibly due to an imbalance.
• Lurching gait, which is characterized by long and slow strides accompanied by pronounced movement of the upper body to reduce weight on a particular leg.  
• Antalgic gait, which is a limping gait caused by pain.
• Propulsive gait, which affects patients dealing with Parkinson’s disease, is a propulsive gait that features short, quick steps, and a stooped posture with head and neck bent forward. 
• Scissors gait, which may be seen with patients with spastic cerebral palsy, sees knees and thighs crossing over each other as a patient walks. 
• Spastic (or hemiplegic) gait is where a patient is afflicted with one stiff leg that they drag or swing as they walk.
• Steppage (or neuropathic) gait sees a patient elevate their hip to lift their leg higher than they normally would, with and toes pointed down and dragging the ground as they walk. 
• Waddling gait, which can result from progressive muscular dystrophy or hip dislocation, can cause exaggerated upper body movement. 
• Crouching gait, which may be seen with cerebral palsy patients, may cause ankles, knees, and hips to flex while you walk.   

What is the ICD-10 code for unsteady gait?

If you’re looking for the right ICD-10 code for unsteady gait during an initial encounter with a patient dealing with unsteady gait, you have a few options. You could choose R26.81, unsteadiness on feet, which is a commonly used code of gait-related conditions. However, there are also several other ICD-10 codes under the R26 parent code that might be more specific, and thus more applicable to a particular patient’s condition:

• R26.0, Ataxic gait
• R26.1, Paralytic gait
• R26.2, Difficulty in walking, not elsewhere classified

There is also R26.89, Other abnormalities of gait and mobility, which, as listed in this resource,  includes a number of approximate synonyms:  

• Cautious gait
• Gait disorder due to weakness
• Gait disorder, multifactorial
• Gait disorder, painful gait
• Gait disorder, postural instability
• Gait disorder, weakness
• Gait disturbance, senile
• Limp in childhood
• Limp occurring during childhood
• Limping child
• Multifactorial gait problem
• Painful gait
• Toe walking
• Toe-walking gait
• Unsteady when walking

Finally, there’s R26.9, Unspecified abnormalities of gait and mobility, which includes approximate synonyms for 

• Abnormal gait
• Functional gait abnormality
• Gait abnormality
• Gait abnormality, functional (nonphysiologic)

For the R26 family of ICD-10 codes, there are Excludes1 edits for: 

• ataxia NOS (R27.0)
• hereditary ataxia (G11.-)
• locomotor (syphilitic) ataxia (A52.11)
• immobility syndrome (paraplegic) (M62.3)

As you can see, there’s a lot of nuance to the seemingly simple ICD-10 code for unsteady gait. Clinicians have the tools and the knowledge to correctly diagnose what’s afflicting a particular patient, but billing and coding aren’t something the typical DPT program is teaching—which is why we’re here to help guide you through the alphanumeric maze of ICD-10. If you‘ve got questions about some of the other common diagnosis codes for rehab therapy, check out our blogs on the ICD-10 code for low back pain and the ICD-10 code for deconditioning.