Home Health ICD-9/ICD-10 Alert

Question: What diagnosis should I report for a patient who falls frequently?

Answer: Some coders say the majority of falls they see are due to syncope (780.2). That's an appropriate code if the physician diagnoses the patient with syncope, but it isn't your only option. Falling without cause is often a neurological problem.

Potential choices range from 781.2 (Abnormality of gait) or 781.3 (Lack of coordination) to V15.88 (History of fall). If you know specific details about the fall, and there was an injury, include an E code that describes the circumstances. If you don't know the details of the fall that caused the injury, however, some coders recommend E888.x (Other and unspecified fall).

Tip: Do not report an E code if there was no injury. If you plan to code beyond "personal history of falls," verify with the provider about the cause to ensure you accurately report the patient's condition.