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P94.2
ICD-10-CM
Hypotonia

Understand hypotonia diagnosis, clinical documentation, and medical coding. Find information on hypotonia symptoms, causes, ICD-10 codes (e.g., R29.81, G80-G83), CPT codes for related procedures, and best practices for healthcare professionals documenting hypotonia in patient charts. Explore resources for differential diagnosis and treatment of hypotonia in infants, children, and adults. This comprehensive guide covers the essential aspects of hypotonia for accurate medical coding and clinical care.

Also known as

Floppy Baby Syndrome
Decreased Muscle Tone

Diagnosis Snapshot

Key Facts
  • Definition : Decreased muscle tone, often resulting in reduced strength and floppy movements.
  • Clinical Signs : Weakness, reduced reflexes, joint hyperflexibility, delayed motor skills.
  • Common Settings : Pediatric neurology, genetics clinics, physical therapy, occupational therapy.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC P94.2 Coding
R29.81

Hypotonia

Generalized decreased muscle tone.

G80-G83

Cerebral palsy and other paralytic syndromes

Hypotonia can be a symptom of cerebral palsy and related disorders.

Q90-Q99

Chromosomal abnormalities

Certain chromosomal abnormalities can cause hypotonia.

G70-G73

Muscular dystrophies and other myopathies

Some muscular dystrophies and myopathies present with hypotonia.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is hypotonia congenital?

  • Yes

    Specific syndrome documented?

  • No

    Associated with other condition?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Decreased muscle tone.
Cerebral palsy
Down syndrome

Documentation Best Practices

Documentation Checklist
  • Hypotonia diagnosis: Onset, duration, severity
  • Muscle tone assessment: Specific muscles tested
  • Functional impact: Feeding, mobility, respiration
  • Associated symptoms: Developmental delays, genetic conditions
  • ICD-10 code: R29.81 (Hypotonia, unspecified)

Coding and Audit Risks

Common Risks
  • Unspecified Hypotonia

    Coding R53.8 (Hypotonia, unspecified) without documenting the underlying cause leads to inaccurate severity and reimbursement.

  • Congenital vs. Acquired

    Failure to distinguish between congenital (e.g., P94.2) and acquired hypotonia impacts quality metrics and treatment plans.

  • Comorbidity Coding

    Missing documentation of related conditions like Down Syndrome or Cerebral Palsy with hypotonia affects risk adjustment and resource allocation.

Mitigation Tips

Best Practices
  • Document hypotonia etiology for ICD-10 accuracy (R29.81).
  • CDI: Detail hypotonia severity and impact on function.
  • PT/OT referrals crucial for hypotonia intervention, document thoroughly.
  • Regular developmental assessments key for hypotonia management and compliance.
  • Genetic testing consideration for hypotonia, impacts coding and care.

Clinical Decision Support

Checklist
  • Review: Age at onset, muscle weakness, head control?
  • Assess: Deep tendon reflexes, joint hypermobility?
  • Check: Family history, genetic testing (if indicated)?
  • Document: Specific hypotonia findings, differential diagnoses

Reimbursement and Quality Metrics

Impact Summary
  • Hypotonia reimbursement hinges on accurate ICD-10-CM coding (e.g., R29.81) and supporting documentation for medical necessity.
  • Coding quality directly impacts hypotonia case mix index (CMI) and hospital reimbursement.
  • Precise hypotonia coding affects quality reporting metrics like severity of illness (SOI) and risk of mortality (ROM).
  • Timely and specific hypotonia documentation improves claim processing and reduces denials.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes for . Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • Code primary cause of hypotonia
  • Document severity and impact
  • Specify congenital or acquired
  • Consider 728.87 for NOS
  • Review neuromuscular codes

Documentation Templates

Patient presents with signs and symptoms consistent with hypotonia, characterized by decreased muscle tone, also referred to as floppy baby syndrome or benign congenital hypotonia.  The patient exhibits reduced resistance to passive movement, joint hypermobility, and generalized weakness.  Differential diagnosis includes cerebral palsy, muscular dystrophy, spinal muscular atrophy, Down syndrome, Prader-Willi syndrome, and other genetic or metabolic disorders.  Assessment includes a thorough neurological examination, evaluation of developmental milestones, and family history.  Diagnostic testing may include genetic testing, metabolic screening, electromyography (EMG), nerve conduction studies, and brain imaging such as MRI or CT scan.  Current presentation suggests [specify level of severity: mild, moderate, or severe] hypotonia.  Treatment plan focuses on supportive care, including physical therapy, occupational therapy, and speech therapy to improve motor skills, strength, and functional abilities.  Genetic counseling may be indicated if a genetic cause is suspected.  Prognosis depends on the underlying etiology and severity of the hypotonia.  Follow-up care is essential for ongoing monitoring of developmental progress and adjustments to the treatment plan as needed.  ICD-10 code R29.81 (Hypotonia) is assigned.  CPT codes for relevant procedures, such as neurological examination (99202-99205) and therapeutic exercises (97110), will be documented separately.  Continued monitoring and assessment are crucial to optimize patient outcomes and address any complications or comorbidities associated with hypotonia.