Internal Medicine Coding Alert

Question: An established patient came to the office complaining of back pain related to a fall three weeks ago. We aren't sure of the allowable timeframe for coding falls. Can we still report an E code?

New Hampshire Subscriber

Answer: The HIPAA mandated ICD-9 coding guidelines state that you should assign the appropriate E code for the initial encounter of an injury but not for subsequent treatment. Although you're treating an established patient, this is the first time your physician has seen the patient because of this particular injury. If documentation supports its use, include the appropriate choice from E880-E888 ("Accidental falls") to describe the reason for falling.