Neurology & Pain Management Coding Alert

Double check notes before falling for easy answers.

The neurologist wrote "frequent falls" on a patient's chart, so now you're faced with choosing the best diagnosis code. Answer these three questions to narrow the options.

Question 1: Is This a New Problem?

Your first step in assigning a diagnosis is to verify whether the patient has an extended history of frequent falls.

"I've seen my doctors refer in the HPI that the patient has had frequent falls, which indicates deviation from the norm for the patient," says Vonda Pickelsimer, a coder with Neurology Associates of Greenville, S.C. "Sometimes they note injuries due to the fall, such as superficial injuries, lacerations, or broken bones."

If the neurologist verifies a history of falls, add V15.88 (Other specified personal history presenting hazards to health; history of fall). Note that ICD-9 explanations specify that V15.88 also applies to "at risk for falling."

"Typically, the neurologist would elicit the history of fall information during the history portion of the E/M service," says Marvel Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver. Factors the physician considers could include the duration of falls, the context of falls, what the patient has done to help prevent falls. "Depending on the likelihood for future falls or the importance of the falls with a patient's chief complaint, the neurologist might order additional diagnostic tests and/or services to help the patient decrease her potential to fall," Hammer says.

Question 2: Does the Doctor Mention Syncope?

Next, ascertain what's causing the falls. Frequent falls can be associated with syncope, a partial or complete loss of consciousness due to temporary reduction in blood flow and shortage of oxygen to the brain. Don't make this assumption, however, and automatically report 780.2 (Syncope and collapse).

More possibilities: Quiz your physician for underlying causes of the falls. Signs and symptoms such as 781.2 (Abnormality of gait), 781.3 (Lack of coordination), or 780.4 (Dizziness and giddiness) might be more accurate until is the physician documents an established etiology for the falls. Diagnoses such as gait abnormality and lack of coordination don't carry the significance of a diagnosis such as syncope.

"I always review the General and Neurological Exam section of the report for results of the gait, sensory, motor, and musculoskeletal areas examined," Pickelsimer says. Try these steps:

"If the medical record indicates normal gait and coordination issues and doesn't indicate syncope, then code the patient's other symptoms," Pickelsimer says. Underlying medical conditions that could contribute to frequent falls range from multiple sclerosis (340) or Parkinson's disease (332.0) to diabetic polyneuropathy (250.6x, Diabetes with neurological manifestations), balance disorders such as benign paroxysmal positional vertigo (386.11), and more.

Question 3: Does an E Code Apply?

When going through your neurologist's documentation, check for any notes describing the circumstances of the fall. Details can lead you to an E code such as E880.1 (Fall on or from sidewalk curb) or E884.4 (Fall from bed). If you don't have clear documentation of the fall, report E888.9 (Unspecified fall).

Remember: E codes don't replace more specific diagnoses, but can help give the payer a better picture of the situation. Report E codes as secondary ICD-9 codes in conjunction with ICD-9 codes from the tabular list or V code section that explain the patient's condition.