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Home/Diagnosis/ICD-10 Coding for Tripped and Fall

ICD-10 Coding for Tripped and Fall

W18.40XA
Z91.81

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

Also Known as:
Slipping and Tripping
Ground-Level Fall
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Key Information: ICD-10 Coding for Tripped and Fall

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

Use ICD-10 code W18.40XA for unspecified fall, initial encounter, ensuring proper documentation in clinical notes.

Primary ICD-10-CM Codes

Unspecified fall, initial encounter

Billable Code
W18.40XA
Billable

Diagnostic Criteria

clinical:
  • • Patient reports slipping or tripping without a complete fall.

Applicable To

  • • Slipping without falling
  • • Tripping without falling

Important Notes

  • • Ensure documentation specifies the mechanism of the near-fall.

History of falling

Billable Code
Z91.81
Billable

Applicable To

  • • Recurrent falls

Important Notes

  • • Ensure history is well-documented in the patient's medical record.
Ancillary Codes

Additional codes that may be used with this diagnosis

R29.6

Tendency to fall, not elsewhere classified

Use when documenting a patient's tendency to fall.

Frequently Asked Questions

What is the ICD-10 code for tripped and fall?

The ICD-10 code for a tripped and fall incident is W18.40XA, used for unspecified falls during the initial encounter.

How do you document a fall in a medical record?

Document the fall mechanism, activity at the time, and surface type. Include any injuries sustained and relevant history of falls.

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