Find information on diagnosing and documenting poor balance, including ICD-10 codes R26.81 and R26.89, balance assessment tests, differential diagnosis considerations, and related terms like disequilibrium, ataxia, and postural instability. This resource helps healthcare professionals accurately document and code poor balance for clinical care, insurance claims, and medical research. Learn about common causes, evaluation methods, and treatment options for patients experiencing balance problems.
Also known as
Balance impairment
Disturbance of equilibrium not elsewhere classified.
Other lack of coordination
Includes abnormalities of gait and balance.
Vertigo of central origin
Dizziness and balance issues due to problems within the brain.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the poor balance due to dizziness/vertigo?
Yes
Is vertigo specified?
No
Is there a documented neurological condition?
When to use each related code
| Description |
|---|
| Poor Balance |
| Vertigo |
| Ataxia |
Coding R26.8 (Poor balance) without specifying underlying cause lacks clinical detail, impacting reimbursement and quality metrics. CDI can query for specifics.
Miscoding vertigo (H81.-) as poor balance (R26.8) leads to inaccurate reporting. CDI should clarify symptoms for appropriate code assignment.
Insufficient documentation of balance issues hinders accurate coding and may trigger audits. CDI can improve documentation to support R26.8 or more specific diagnoses.
Patient presents with complaints of impaired balance, instability, and difficulty maintaining equilibrium. Symptoms include unsteadiness, swaying, frequent falls or near falls, and difficulty with ambulation, particularly on uneven surfaces. Assessment reveals deficits in postural stability, including a positive Romberg test and difficulty with single-leg stance. Patient reports feeling unsteady when changing positions, such as sit-to-stand transfers. Gait analysis demonstrates a widened base of support and decreased stride length. Differential diagnosis includes vestibular disorders, cerebellar dysfunction, proprioceptive deficits, and neuromuscular weakness. Causes of balance problems may be related to age-related decline, medication side effects, neurological conditions, musculoskeletal impairments, or visual disturbances. Plan includes physical therapy for balance retraining exercises, vestibular rehabilitation if indicated, and assessment for assistive devices such as a cane or walker to improve safety and mobility. Patient education provided regarding fall prevention strategies and home safety modifications. Follow-up scheduled to monitor progress and adjust treatment plan as needed. ICD-10 code R26.81 (Instability of gait) and CPT codes for evaluation and management services, therapeutic exercise (97110), and gait training (97116) may be applicable depending on specific services provided.