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Question: A patient presented to the provider after falling twice in the past two weeks. The documentation says the patient has fallen in the past but not recently, until these episodes. Would it be appropriate to use both R29.6 and a relevant Z code in this situation? 

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Answer: Yes, according to the guidelines in ICD-10-CM Chapter 18: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (R00-R99), this situation could warrant the use of both diagnosis codes.

Since the patient is presenting to the provider for investigation of the cause(s) contributing to the recent falls, you’d assign code R29.6 (Repeated falls).

However, if the provider documents that the patient had an interval without falls and is now suffering repeated falls again, you could also assign Z91.81 (History of falling).

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC