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2025 ICD-10-CM code R26.0

Ataxic gait, a staggering and unsteady gait.

Code R26.0 is used for ataxic gait of any etiology.It is not to be used if the underlying cause is known and coded elsewhere. For example, if the ataxia is due to multiple sclerosis, the code for MS should be used as the primary diagnosis, and R26.0 may be used as a secondary code to specify the gait abnormality.

Medical necessity for services related to ataxic gait depends on the underlying cause and the specific interventions required.The documentation should support the need for diagnostic testing, therapy, or other treatments.

Clinicians should evaluate the underlying cause of the ataxic gait, which may involve neurological examination, imaging studies, and other tests as needed.

In simple words: An ataxic gait is a clumsy, unsteady way of walking, where the person may stagger or appear drunk, even though they are not. This can happen when there is a problem with the part of the brain that controls balance or with the nerves that tell the brain where the body is in space.

Ataxic gait is characterized by an unsteady, staggering walk, often with a wide base and irregular steps. It can be caused by damage to the cerebellum or by a loss of sensory input, particularly proprioception (sense of body position).

Example 1: A patient presents with a wide-based, unsteady gait, and difficulty maintaining balance.Upon examination, they exhibit dysmetria and nystagmus. The physician diagnoses a cerebellar stroke and codes the gait abnormality as R26.0., An individual with multiple sclerosis experiences worsening balance problems and a staggering gait. The neurologist documents ataxic gait and codes it as R26.0, recognizing it as a manifestation of the underlying disease., Following a spinal cord injury, a patient exhibits difficulty with walking, balance and coordination. Their gait is documented as ataxic and coded R26.0.

Documentation should describe the characteristics of the gait, any associated neurological findings, and the suspected underlying cause. If the ataxia is due to a specific condition, that condition should also be coded.

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