ICD-10 Coding for Hypotonia(P94.2, R27.8)
Complete ICD-10-CM coding and documentation guide for Hypotonia. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Hypotonia
P94.2Primary Range
Congenital hypotonia
Used for cases of hypotonia present at birth, often associated with low Apgar scores and specific neonatal physical findings.
Other lack of coordination
Used for acquired hypotonia due to non-congenital causes such as trauma or metabolic disorders.
Cerebral palsy, unspecified
Used when hypotonia is a symptom of cerebral palsy, requiring coding of the primary condition first.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| P94.2 | Congenital hypotonia | Use for neonates with hypotonia present at birth, confirmed by clinical examination and low Apgar scores. |
|
| R27.8 | Other lack of coordination | Use for hypotonia acquired after birth due to specific causes. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for congenital hypotonia
Essential facts and insights about Hypotonia
Primary ICD-10-CM Codes for hypotonia
Decision Criteria
clinical Criteria
- Presence of hypotonia at birth with supporting neonatal findings.
Applicable To
- Floppy infant syndrome
Excludes
- Acquired hypotonia
Clinical Validation Requirements
- Low Apgar scores
- Frog-leg posture
- Weak suck reflex
Code-Specific Risks
- Misclassification if not confirmed by neonatal history and examination.
Coding Notes
- Ensure documentation includes specific neonatal findings and history.
R27.8 - Other lack of coordination
Use for hypotonia acquired after birth due to specific causes.
Applicable To
- Acquired hypotonia
Excludes
- Congenital hypotonia
Clinical Validation Requirements
- Documented trauma or metabolic cause
- Onset after neonatal period
Coding Notes
Ensure documentation specifies cause and onset of hypotonia.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Hypotonia to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code P94.2.
Impact
Clinical: May lead to misdiagnosis., Regulatory: Increases risk of audit., Financial: Potential for denied claims.
Mitigation Strategy
Always document onset and context of hypotonia.
Impact
Reimbursement: May lead to reduced reimbursement due to lack of specificity., Compliance: Increases risk of audit and non-compliance., Data Quality: Decreases accuracy of patient records.
Mitigation Strategy
Always specify whether hypotonia is congenital or acquired.
Impact
High risk of audit when unspecified codes are used for hypotonia.
Mitigation Strategy
Ensure all documentation specifies whether hypotonia is congenital or acquired.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Hypotonia, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Hypotonia
Use these documentation templates to ensure complete and accurate documentation for Hypotonia. These templates include all required elements for proper coding and billing.
Neonatal hypotonia assessment
Specialty: PediatricsRequired Elements
- Prenatal history
- Apgar scores
- Physical exam findings
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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