2025 ICD-10-CM code G25.81
(Active) Effective Date: N/A Diseases of the nervous system - Other extrapyramidal and movement disorders 6 (Diseases of the Nervous System) Feed
Restless legs syndrome (RLS).
No modifiers are applicable to ICD-10-CM codes.
Medical necessity for treatment of restless leg syndrome is established by the presence of characteristic symptoms that significantly impact the patient's quality of life, particularly sleep and daytime functioning.Documentation should clearly demonstrate the severity of symptoms and the failure of conservative measures (if any were tried) to provide relief.
Diagnosis of RLS is primarily based on patient history and symptoms including the urge to move legs, discomfort worsening during rest, relief with movement, and symptom exacerbation in the evening/night.A physical and neurological exam helps rule out other conditions. Blood tests (e.g., for iron deficiency) and sleep studies may be ordered. Treatment may include iron supplements, medications like gabapentin, pregabalin, dopamine agonists (ropinirole, pramipexole, rotigotine), opioids, muscle relaxants, and sleep aids.
In simple words: Restless legs syndrome (RLS) makes you feel like you need to move your legs. You might have uncomfortable feelings in your legs, like throbbing or aching, especially when you're sitting or lying down. It usually happens in the evening or at night. Moving your legs makes it feel better for a little while.
Restless legs syndrome (RLS), also known as Willis-Ekbom disease, is a neurological disorder characterized by an irresistible urge to move the legs, usually accompanied by uncomfortable sensations like throbbing, creeping, or aching. These sensations typically begin or worsen during periods of rest or inactivity, particularly in the evening or at night.Movement provides temporary relief.The exact cause of primary RLS is unknown, but it is thought to be related to a dysfunction in the basal ganglia, the part of the brain that controls movement, and dopamine regulation. Secondary RLS can be caused by iron deficiency, certain medical conditions (such as end-stage renal disease, diabetes, and peripheral neuropathy), pregnancy, or medications.
Example 1: A 65-year-old female presents with complaints of an uncomfortable creeping sensation in her legs, particularly at night, prompting her to constantly move them.Symptoms worsen with rest and improve with activity.She reports difficulty sleeping due to these sensations. After ruling out other causes, a diagnosis of restless legs syndrome is made., A 35-year-old pregnant woman experiences uncomfortable sensations in her legs during the third trimester, especially at night.The sensations are relieved by movement.Given her pregnancy and the characteristic symptoms, a diagnosis of restless legs syndrome is made.Iron levels are checked., A 40-year-old male with end-stage renal disease undergoing dialysis complains of uncomfortable leg sensations that begin in the evening and worsen when he tries to relax. Moving his legs provides temporary relief. The symptoms are suggestive of secondary restless legs syndrome related to his underlying kidney disease.
Documentation should include a detailed description of the patient's symptoms (onset, duration, character, exacerbating and relieving factors), family history, relevant medical history (including any underlying conditions, current medications, and pregnancy status), physical exam findings, and results of any diagnostic tests (e.g. iron studies, sleep study). It's crucial to document the impact of symptoms on sleep and daily activities.
- Payment Status: Active
- Specialties:Neurology, Sleep Medicine, Nephrology, Primary Care
- Place of Service:Office, Inpatient Hospital, Outpatient Hospital, Telehealth Provided in Patient’s Home, Telehealth Provided Other than in Patient’s Home