Wiki Ambulatory Dysfunction?

[ancoleman22]

We are currently having a discussion at my office about whether or not we can use "acute ambulatory dysfunction" as a dx. My supervisor states that it is not a dx and that we need to return the chart for more documentation. I am just wondering what other facilities/practices use? I work for a home health agency so it is sometimes hard to get more documentation. Thanks!

 

[JMarieBrandt]

Its a vague Dx. A sign/symptom that wont return much for case mix points. I always try to find a more definitive Dx before assigning anything like that. So i understand her position.... if you can find what is causing the ambulatory dysfunction, go with that. But i know... we in home health dont always get that. so you just have to go with what you got

 

[AlanPechacek]

Dysfunctional Gait

This "diagnosis" is too vague and "nonspecific" for use. The R26: Abnormality of gait and mobility would cover it as a Symptom or Physical Finding (Sign), but R Codes should not be used as "diagnosis" code unless there is no other "specific" underlying, causative disease that can be coded for specificity. The "abnormality of gait" is a essentially a manifestation of some other disease, not a disease in and of itself.

Respectfully submitted, Alan Pechacek, M.D.
icd10orthocoder.com

 

[ancoleman22]

Thank you both for the clarification! The problem we have at our facility is that this is all we get a lot of times. There is no definitive diagnosis that is causing it or we cant get anything from the doctor of a diagnosis. My supervisor was telling me that we couldn't use the gait abnormality code R26.9 for ambulatory dysfunction, which didn't make sense to me! Thanks again!