ED Coding and Reimbursement Alert

Read the rules about including Z codes describing a risk or history of falling

ICD-10 may be a trip, but you don’t have to get tripped up when coding for falls in the ED setting with this helpful guidance.

When a patient presents to the ED for evaluation after a fall, there are a myriad of ICD-10 coding concepts for both the coder and the ED physician to be aware of in order for the encounter coding to be as accurate and as specific as possible, says Stacie Norris, MBA, CPC, CCS-P, Director of Coding Quality Assurance for Zotec Partners in Durham, NC.

With ICD-10, you have R29.6 (Repeated falls).  According to the ICD-10 guidelines you would use R29.6 when a patient has recently fallen and the reason for the fall is being investigated. As the name implies, this code should be assigned when there is documentation that this isn’t just a situation of one isolated fall, but of multiple falls, says Norris.

There is also another code available in ICD-10 for falls:  Z91.81 (History of falling). This code is to be used when the patient has fallen before and is at risk for future falls. However, coders should not code Z91.81 as a primary diagnosis unless there is no other alternative, as this code is from the “Factors Influencing Health Status and Contact with Health Services,” similar to the V-code section from ICD-9.

The diagnosis codes from this section are often denied by payers as not supporting the medical necessity for the claim, advises Norris.  Note that there is an “Excludes 2 note” for code Z91.81 when using R29.6, hence supporting that if the documentation supports, both codes can be used together, i.e., one is not included in the other: as shown in the ICD-10 book:

R29.6 Repeat Falls

Falling

Tendency to fall

Excludes at risk for falling (Z91.81)

History of falling (Z91.81)

Chose The Most Specific Diagnosis Code the Chart Documentation Supports

Finally, if the coder reviews the documentation and is in the unfortunate situation of having no other diagnosis (or sign/symptom) to use except “Fall”, then the appropriate ICD-10 code to use is Z04.3 (Encounter for examination and observation following other accident).

This is not a desirable coding situation because, as noted above, Z-codes are often denied and do not clearly reflect the acuity of the patient encounter. This particular Observation Z-code is particularly prone to denials by payers. Provider should be educated about the importance of documenting all the circumstances of the fall, if this is a situation of repeated falls, as well as any injuries, contributing conditions, or sign/symptoms.

In addition to the codes already mentioned, if there is an injury as a result of the fall, then the appropriate acute injury code will be assigned in addition to the External Cause code(s) (if External Cause are required by payor or other guidelines for the physician group). If the fall was caused by other conditions or symptoms, such as vertigo or weakness, then these conditions will also be coded and will help to support the medical necessity of the claim, Norris explains.