# Dx for 12 month old who fell but has no injury?



## coding303 (Feb 4, 2014)

The patient is 12 months old and rolled down a number of stairs.  Mom brought her in to be seen just in case.  There is nothing wrong, physical exam is normal.  Mom denies head injury, child is acting normal.  Now I am not sure how to code this as all I have is an e-code.  Does anyone have any experience with this?  Will this be a reimbursable visit at all?  I know I can't code an e-code as primary but I have no other Dx available.  PLEASE HELP


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## rhondatalley (Feb 4, 2014)

*fall with no dx.*

V71.4 - observation following accident.


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## phims01 (Feb 4, 2014)

I would recommend using V71.4 Observation following other accident.  There are Coding Clinic references associated with this code that would support this code assignment in the scenario you described.  It may be advisable to add the E-Codes to this account as additional diagnosis.  This may assist in "explaining" the use of V71.4 as First Listed for the visit to the payer.  My recommendations would probably be: E880.9 Fall down other stairs or steps; E029.9 Other Activity; E000.8 Other external cause status; E849.0 Accident occuring in the home.....these E-Codes are dependent upon supporting documentation.


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## MarcusM (Feb 5, 2014)

Absolutely no contusions? Or sprain/strains?


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