2025 ICD-10-CM code R27.0
Ataxia, unspecified.
The medical necessity for using R27.0 rests on the presence of clinical findings indicative of ataxia. The code is appropriate when a more specific diagnosis cannot be made after investigation, or when the ataxia is transient and resolves without a definitive cause being identified.
- Chapter 18: Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)
- R25-R29: Symptoms and signs involving the nervous and musculoskeletal systems
In simple words: This code signifies a general lack of muscle coordination, making it difficult to perform voluntary movements smoothly.It's used when the specific cause or type of ataxia isn't clear.
Ataxia is a lack of muscle coordination that can affect various voluntary movements.It can manifest in the limbs, trunk, eyes, and even speech (affecting the pharynx and larynx). This impaired coordination can stem from problems with sensory or motor function.Sensory ataxia is linked to issues with the posterior column of the spinal cord or peripheral nerves, while motor ataxia can be related to problems in the cerebellum, cerebral cortex, thalamus, basal ganglia, or the red nucleus.
Example 1: A patient presents with unsteady gait and difficulty with fine motor skills. After initial examination, the physician suspects ataxia but needs further investigation to pinpoint the underlying cause. R27.0 is used until a definitive diagnosis is made., A patient experiences a sudden onset of incoordination during an emergency room visit.Tests rule out stroke or other acute conditions. The incoordination resolves within 24 hours without a clear cause.R27.0 is used to document the transient ataxia., A patient with a history of multiple sclerosis develops worsening ataxia.R27.0 is used if the documentation doesn't specify the type of ataxia (e.g., sensory or cerebellar), or if it's not clearly linked to MS exacerbation in the documentation.
Documentation should support the presence of ataxia, describing the specific movements affected and the severity of the incoordination. Any associated symptoms or neurological findings should also be documented. If known, document possible causes or related conditions that have been considered or ruled out.
** R27.0 should not be used for abnormal findings on antenatal screening (O28.-) or conditions originating in the perinatal period (P04-P96).
- Specialties:Neurology, Physical Medicine and Rehabilitation, Geriatrics, Emergency Medicine
- Place of Service:Inpatient Hospital, Outpatient Hospital, Office, Emergency Room - Hospital, Skilled Nursing Facility