Diagnosis for mobility dysfunction

colham478

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Perrysburg, OH
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We have a Physical Medicine and Rehab specialist in our office who was referred a patient from one of our Ortho surgeons for evaluation of how to best progress this patients mobility after sustaining bilateral tibial fractures. I am looking for a Dx code that best fits the patient's mobility dysfunction which is slap in the face obvious because the patient has bilateral tibial fractures and is in a wheelchair. I really don't want to use the fx codes as primary due to the patient being in global with the surgeon. I have considered abnormality of gait -781.2 and difficulty in walking -719.7 Both which seem extremely cliche, but I am leaning more toward 719.7. The patient shows no neurological issues and sensation is intact. Patient has wounds on legs which do hinder walking, and healing fractures. Pt is in post op with surgeon, but PM&R can bill as seperate speciality. PM&R is new to our office, so any advice would be appreciated.
Thanks!!
 

MCJCCH

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I am the coder for a PM&R clinic and we use 799.3 for impaired mobility. 781.2 is talking about the patients gait and if they had an abnormal gait or gait dysfunction. You can also use the late effect fracture codes for secondary diagnosis since the impaired mobility is a late effect of the tibial fracture. I would code as follows 799.3 as pdx and 905.4 as the seconday dx
 
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