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
Hypotonia
Generalized decreased muscle tone.
Cerebral palsy and other paralytic syndromes
Hypotonia can be a symptom of cerebral palsy and related disorders.
Chromosomal abnormalities
Certain chromosomal abnormalities can cause hypotonia.
Muscular dystrophies and other myopathies
Some muscular dystrophies and myopathies present with hypotonia.
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?
When to use each related code
Description |
---|
Decreased muscle tone. |
Cerebral palsy |
Down syndrome |
Coding R53.8 (Hypotonia, unspecified) without documenting the underlying cause leads to inaccurate severity and reimbursement.
Failure to distinguish between congenital (e.g., P94.2) and acquired hypotonia impacts quality metrics and treatment plans.
Missing documentation of related conditions like Down Syndrome or Cerebral Palsy with hypotonia affects risk adjustment and resource allocation.
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.