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2025 ICD-10-CM code R54

Age-related physical debility, frailty, or general weakness in adults.

Use this code only when the primary reason for the encounter is age-related physical debility.If a more specific diagnosis (such as sarcopenia) can be established, use the appropriate code instead.Refer to the ICD-10-CM guidelines for more specific instructions.

Modifiers may be applicable depending on the circumstances of the visit and any procedures performed. Consult your local guidelines.

Medical necessity for treatment related to R54 would be established by demonstrating that the patient's age-related physical debility significantly impairs their ability to perform ADLs, and that interventions (physical therapy, occupational therapy, etc.) are reasonably likely to improve their function and quality of life.

The clinical responsibility depends on the underlying cause of the age-related physical debility.It may involve a geriatrician, general practitioner, physical therapist, occupational therapist, or other specialists, depending on the patient's specific needs and the complexity of their case.

IMPORTANT Consider M62.81 (Generalized muscle weakness), M62.84 (Sarcopenia), or R53.81 (Other malaise) depending on the specific cause and presentation of the weakness. R54 specifically addresses age-related debility, while other codes may be more appropriate for weakness stemming from other underlying conditions.

In simple words: This code describes physical weakness or frailty that comes with aging. It means the body is losing its strength and ability to do things easily.This is different from weakness caused by other health problems.It's usually used for adults.

This code, R54, is used to classify age-related physical debility.It encompasses a decline in physical function due to age-related factors, often manifesting as frailty, weakness, and reduced endurance.This code is specifically for age-related physical impairments, distinguishing it from other causes of weakness or debility. The code applies to adults aged 15-124 years old.It excludes specific conditions like sarcopenia (M62.84), senile psychosis (F03), and age-related cognitive decline (R41.81).

Example 1: An 80-year-old patient presents with increasing fatigue, decreased mobility, and difficulty performing activities of daily living (ADLs).Physical examination reveals generalized weakness and muscle atrophy.R54 is appropriate, unless another cause is identified and coded., A 75-year-old patient experiences a fall resulting in a hip fracture.Post-surgery, she displays significant weakness and decreased mobility. R54 might be used in conjunction with codes related to the fracture and its treatment, depending on the context and primary reason for the visit., A 68-year-old patient reports persistent fatigue and decreased stamina that interferes with everyday activities. They have no specific underlying disease identified and their symptoms are exclusively related to age-related physical decline. R54 is appropriate.

A thorough history and physical examination documenting the patient's age, functional limitations, activities of daily living (ADL) impairments, and any other relevant symptoms.Laboratory investigations (as needed) to rule out other potential causes of weakness.Documentation supporting the medical necessity of any ordered treatments or therapies.

** R54 is often used in conjunction with other codes to fully represent the patient's condition.Detailed documentation is crucial to ensure accurate coding and reimbursement.

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