Complete ICD-10-CM coding and documentation guide for icd-10 coding for trip and fall includes clinical validation requirements, medical necessity guidelines, and coding policies.
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Essential facts and insights about ICD-10 Coding for Trip and Fall
Use ICD-10 code W01.0XXA for fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter, ensuring proper documentation in clinical notes.
Additional codes that may be used with this diagnosis
Place of occurrence, home
Document the location of the fall.
The ICD-10 code for a trip and fall without striking an object is W01.0XXA. If the fall involves striking an object, use W01.1XXA.
Use Z04.3 for encounters where no injury is found and the reason for the fall is unclear.
Z91.81 should be used to document a history of falls impacting current care, not as a primary diagnosis.