Many times, lower extremity weakness is documented on the patient’s assessment. Should lower extremity weakness be coded as muscle weakness? Absolutely not.
Lower extremity weakness, without mention of muscle weakness should be assigned code 729.89, other musculoskeletal symptoms referable to limbs.
If your patient is receiving physical therapy, always remember to check the manual muscle test (MMT) scores documented by the therapist on the assessment. If the scores are low, then you can question whether or not it’s actually muscle weakness affecting the lower extremities.
ICD-10-CM
R29.898 Other symptoms and signs involving the musculoskeletal system
M62.81 Muscle Weakness
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