Ataxic gait

This code describes an unsteady, uncoordinated walking pattern characterized by a wide-based stance, irregular foot placement, and difficulty maintaining balance. It results from impaired cerebellar function or proprioceptive deficits, leading to a distinctive reeling or staggering gait. Patients often exhibit dysmetria and dysdiadochokinesia in their lower extremities.

Assign this code when documentation explicitly states "ataxic gait" or describes the characteristic uncoordinated, wide-based, and unsteady walking pattern due to cerebellar or sensory ataxia. This code is appropriate when the gait disturbance is the primary focus of the encounter or a significant contributing factor to the patient's presentation. Supporting documentation includes neurological exam findings, physical therapy assessments, and physician notes detailing the gait abnormality.

• Do not use this code for other types of unsteady gait, such as spastic, parkinsonian, or neuropathic gait, unless ataxic features are specifically noted.
• Always code the underlying cause of the ataxic gait first, if known and documented (e.g., cerebellar degeneration, multiple sclerosis).
• Distinguish from "unsteadiness on feet" (R26.81) or "gait disturbance, not elsewhere classified" (R26.9) when the specific ataxic pattern is clearly identified.