Restless Leg Syndrome ICD-10 Code

Content reviewed by Megan Andrews, MSN, APRN, ANP-Cs

Restless legs syndrome (RLS), also called Willis-Ekbom disease, is a neurological disorder characterized by an overwhelming urge to move the legs, often accompanied by uncomfortable sensations such as tingling, burning, or itching. These symptoms typically worsen during times of rest or inactivity, especially at night, leading to disrupted sleep and impaired quality of life.  

What is restless legs syndrome? 

Restless legs syndrome is a sensory-motor disorder that affects millions of people around the world. The hallmark of RLS is an overwhelming urge to move the legs to alleviate uncomfortable sensations, often described as creeping, crawling, tingling, or pulling. These symptoms are most prominent when the patient is at rest, making it difficult to relax or sleep. The discomfort typically improves with movement, such as walking or stretching, but often returns once the patient is stationary again. 

RLS can occur in both men and women, but it is more common in women and tends to worsen with age. While some cases of RLS are idiopathic (without a known cause), it can also be linked to underlying medical conditions such as iron deficiency anemia, kidney disease, diabetes, or peripheral neuropathy. 

ICD-10 code for RLS (restless legs syndrome) 

The ICD-10 code for restless legs syndrome is crucial for documenting and managing the condition in clinical settings. It allows healthcare professionals to classify the condition accurately and ensure that patients receive appropriate care and treatment. 

G25.81 – Restless legs syndrome 

Definition: This code is used for the diagnosis of restless legs syndrome (RLS), a neurological condition characterized by an overwhelming urge to move the legs, usually accompanied by uncomfortable sensations. It is commonly diagnosed based on clinical symptoms and may require further testing to rule out underlying causes. 

Nursing application: Nurses caring for patients with RLS should focus on symptom management, patient education, and addressing any underlying medical conditions that may be contributing to the syndrome. This includes assessing the patient's sleep quality, level of discomfort, and any factors that may exacerbate the condition, such as medications, stress, or iron deficiency. Nurses should also provide strategies to relieve symptoms, such as lifestyle modifications, pharmacological interventions, and non-pharmacological therapies. 

Symptoms and causes of restless legs syndrome 

Patients with RLS often describe symptoms as uncomfortable, unpleasant sensations in the legs that are difficult to ignore. Common symptoms include: 

• Uncontrollable urge to move the legs: This is the primary symptom of RLS and is usually triggered by periods of rest or inactivity. 
• Tingling, burning, or itching in the legs: These sensations are often described as creeping or crawling and can range from mild discomfort to severe distress. 
• Symptoms that worsen at night: RLS symptoms are often more pronounced in the evening or during the night, leading to difficulties with falling asleep or staying asleep. 
• Temporary relief with movement: Walking, stretching, or moving the legs often provides temporary relief from symptoms. 

Causes: While the exact cause of RLS isn’t known, several factors are associated with the condition, including: 

• Genetics: RLS tends to run in families, suggesting a genetic component. 
• Iron deficiency: Low iron levels or abnormal iron metabolism in the brain may contribute to RLS. 
• Pregnancy: Pregnant women, particularly in the third trimester, may experience RLS, though symptoms typically resolve after childbirth. 
• Chronic diseases: Conditions such as chronic kidney disease, diabetes, and peripheral neuropathy have been linked to RLS. 
• Medications: Certain medications, such as antidepressants, antipsychotics, and antihistamines, may exacerbate RLS symptoms. 

Nursing interventions for restless legs syndrome 

Effective nursing care for patients with restless legs syndrome focuses on alleviating symptoms, improving sleep quality, and addressing any underlying health issues that may contribute to RLS. Below are key nursing interventions for managing RLS: 

1. Symptom assessment and monitoring 

Thorough assessment and monitoring of RLS symptoms are essential for developing a personalized care plan. Nurses should evaluate the intensity, frequency, and triggers of the patient's symptoms. 

Application: Nurses should conduct a detailed history of the patient’s symptoms, including when they occur, what makes them worse or better, and how they affect daily functioning and sleep. Regular follow-ups are necessary to track the progression of symptoms and evaluate the effectiveness of treatment strategies. 

2. Sleep hygiene and management 

One of the most significant consequences of RLS is disrupted sleep, leading to chronic fatigue, irritability, and reduced quality of life. Nurses should educate patients on proper sleep hygiene practices to improve sleep quality and reduce nighttime symptoms. 

Application: Nurses should advise patients on the importance of maintaining a consistent sleep schedule, creating a calming bedtime routine, and minimizing distractions such as electronic devices before bed. Encouraging patients to limit caffeine, alcohol, and nicotine intake, especially in the evening, may also reduce RLS symptoms. For patients experiencing severe sleep disturbances, nurses may need to collaborate with sleep specialists. 

3. Non-pharmacological therapies 

Non-pharmacological interventions are often effective in managing mild to moderate RLS symptoms. These interventions can provide relief without the side effects of medications. 

Application: Nurses can recommend several non-pharmacological strategies for relieving symptoms: 

• Leg massages or warm baths: These can help relax the muscles and alleviate discomfort. 
• Hot or cold compresses: Alternating between heat and cold therapy can provide relief from the sensations associated with RLS. 
• Regular exercise: Engaging in physical activity, such as walking, swimming, or yoga, can help reduce the frequency and intensity of RLS symptoms. However, vigorous exercise close to bedtime should be avoided as it may worsen symptoms. 

4. Pharmacological management 

For patients with moderate to severe RLS, medications may be necessary to manage symptoms effectively. Nurses should be aware of the common medications used to treat RLS and monitor for side effects. 

Application: Common medications for RLS include: 

• Dopaminergic agents: Medications such as pramipexole and ropinirole, which increase dopamine levels in the brain, are commonly prescribed to manage RLS symptoms.   
• Iron supplements: If iron deficiency is detected, nurses should ensure that patients take iron supplements as prescribed, monitoring for side effects such as constipation. 
• Anticonvulsants: Medications like gabapentin or pregabalin may be used to treat RLS, especially if symptoms are painful. 
• Opioids or benzodiazepines: These may be considered for severe cases, although they carry a higher risk of dependence and side effects. 

Nurses must instruct patients on the proper use of these medications, potential side effects, and why adherence to the prescribed treatment regimen is important. 

5. Addressing underlying conditions 

Nurses should assess patients for any underlying medical conditions that could contribute to RLS, such as iron deficiency, kidney disease, or diabetes. Managing these conditions can significantly reduce RLS symptoms. 

Application: If iron deficiency is identified, nurses should ensure that patients receive appropriate iron supplementation and dietary advice to improve iron levels. For patients with chronic conditions like diabetes or kidney disease, nurses should work closely with the healthcare team to optimize the management of these conditions, as well-controlled blood sugar or kidney function can reduce RLS symptoms. 

6. Patient education and support 

Providing patient education about restless legs syndrome is essential for helping patients manage their condition effectively. Nurses should offer information on lifestyle modifications, treatment options, and strategies for coping with the emotional and psychological impacts of RLS. 

Application: Nurses should educate patients on the chronic nature of RLS and emphasize the importance of self-management strategies. Patients should be encouraged to keep a symptom diary to identify triggers and monitor the effectiveness of treatments. Additionally, nurses can connect patients with support groups or online communities, where they can share experiences and coping strategies with others who have RLS. 

Preventing complications in restless legs syndrome: The nurse’s role 

While RLS itself is not life-threatening, it can lead to significant complications if left untreated, including sleep disorders, depression, and decreased quality of life. Nurses help prevent these complications by providing comprehensive care and early intervention. 

Key preventative measures: 

1. Improving sleep quality: Nurses should focus on helping patients improve sleep quality through proper sleep hygiene, non-pharmacological treatments, and appropriate use of medications. 
2. Managing iron deficiency: For patients with low iron levels, ensuring appropriate treatment and monitoring iron levels regularly can prevent the worsening of RLS symptoms. 
3. Addressing mental health: Chronic sleep disturbances and discomfort can lead to anxiety, depression, and mood disorders. Nurses should assess patients for signs of mental health issues and refer them to appropriate mental health services if necessary. 
4. Collaborating with healthcare professionals: Nurses should collaborate with physicians, neurologists, and sleep specialists to ensure a holistic approach to managing RLS and addressing any underlying health conditions.