Neurology & Pain Management Coding Alert

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

New Jersey Subscriber

Answer: Some coders say the majority of falls in their practices are due to syncope (780.2). That's an appropriate code if your physician diagnoses the patient with syncope, but it isn't your only option.

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, include an E code that describes the place and circumstances. If you don't know the details, however, some coders recommend E888.x (Other and unspecified fall).

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.