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Home/Diagnosis/ICD-10 Coding for Recent Fall

ICD-10 Coding for Recent Fall

W18.30XA
R29.6

Complete ICD-10-CM coding and documentation guide for icd-10 coding for recent fall includes clinical validation requirements, medical necessity guidelines, and coding policies.

Also Known as:
Ground-level fall
Accidental fall
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Key Information: ICD-10 Coding for Recent Fall

Essential facts and insights about ICD-10 Coding for Recent Fall

Use ICD-10 code W18.30XA for fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter, ensuring proper documentation in clinical notes.

Primary ICD-10-CM Codes

Fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter

Billable Code
W18.30XA
Billable

Diagnostic Criteria

documentation_criteria:
  • • Detailed description of the fall mechanism and surface type
applicable_to:
  • • Slipped on wet floor
  • • Tripped over uneven surface
excludes:
  • • Falls from height (W13-W15)
validation:
  • • Documented mechanism of fall
  • • Surface type (e.g., wet floor)
notes:
  • • Ensure detailed documentation of the fall mechanism to support code selection.
risks:
  • • Insufficient detail on fall mechanism

Repeated falls

Billable Code
R29.6
Billable

Diagnostic Criteria

applicable_to:
  • • Multiple falls in a short period
excludes:
  • • Single fall (W00-W19)
validation:
  • • History of two or more falls
  • • Gait assessment
notes:
  • • Ensure documentation supports the frequency of falls to justify this code.
Ancillary Codes

Additional codes that may be used with this diagnosis

Z91.81

History of falling

Use to document a history of falls, which may indicate increased risk.

W18.30XA

Fall on same level from slipping, tripping and stumbling

Use to specify the mechanism of recent falls.

Frequently Asked Questions

What is the ICD-10 code for a recent fall?

The ICD-10 code for a recent fall is W18.30XA, which describes a fall on the same level from slipping, tripping, and stumbling without subsequent striking against an object.

How do you document a recent fall?

Document the mechanism of the fall, surface type, activity at the time, and any loss of consciousness. Include details like 'tripped over a rug in the living room'.

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