Coding of Weakness


When a patient is admitted for increased generalized weakness and then is covid positive, can weakness be coded as a secondary diagnosis?

The patient is receiving PT and OT services for weakness and requires assistance with ambulation. Upon discharge, the patient will be receiving in home therapy as well due to ongoing weakness. Our coding team had said that if weakness is "inherent" in the diagnosis, such as Covid, then it is not coded as a secondary.

Beth Vorachek, RN, CDI



  • Vague signs and symptoms integral to a known process are generally not coded. There can be exceptions. As a professional coder and a CCDS, I agree with your coding team on this issue.

    There are some references to this in the official coding guidelines if you wish to research.

    P. Evans, RHIA, CCDS

  • If you think appropriate Beth based on review of the chart, this might be a query opportunity if it's not clear whether the weakness is due to COVID or another underlying issue, or multifactorial.

    As Paul stated though if COVID or another condition is identified as causing the weakness then ordinarily that condition would be coded and not the weakness.

    Hope that helps!


  • We use R53.81-Other malaise and R26.9-Unspecified abnormalities of gait and mobility for almost all cases in the IRF setting, and many of our patients are COVID-recovering.



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