Neurosurgery Coding Alert

Question: A patient presents to the neurosurgery practice with a history of falling. Can we report any ICD-10 diagnosis codes for falling?

Georgia Subscriber

Answer: When a patient presents for evaluation after a fall, there are a myriad of ICD-10 coding options. You should aim to select a code as accurate and as specific as possible.

Confirm multiple falls before you submit R29.6: With ICD-10, you have R29.6 (Repeated falls).  According to the ICD-10 guidelines you would use R29.6 when a patient has recently fallen and the reason for the fall is being investigated.

Carefully code for history of falling:  Your question is for a history of falling. For this, you have a specific ICD-10 code, Z91.81 (History of falling). This code is to be used when the patient has fallen before and is at risk for future falls.

Beware: However, coders should not code Z91.81 as a primary diagnosis unless there is no other alternative, as this code is from the “Factors Influencing Health Status and Contact with Health Services,” similar to the V-code section from ICD-9.

Guard for a potential denial: The diagnosis codes from this section are often denied by payers as not supporting the medical necessity for the claim.  Note that there is an “Excludes 2 note” for code Z91.81 when using R29.6, hence supporting that if the documentation supports, both codes can be used together, i.e., one is not included in the other: as shown in the ICD-10 book:

• R29.6 Repeat Falls
• Falling
• Tendency to fall
• Excludes at risk for falling (Z91.81)
• History of falling (Z91.81)