Neurosurgery Coding Alert

Question: In a patient with gait imbalance, our physician documented repeated falls. Can we submit a diagnosis code for this condition? What is the difference between R29.6 and Z91.81?

Texas Subscriber

Answer: With ICD-10, you have R29.6 (Repeated falls) and Z91.81 (History of falling) for the diagnosis of falling in a patient. There is an overlap in the conditions that these two codes cover.

The code R29.6 implies that the patient has had a series of current falls. In most ideal situations, you submit this code when the patient presents with an injury due to one or all of these repeated falls. Your physician may investigate the cause of falling in such patients. On the other hand, you submit code Z91.81 if your physician documents that the patient has had a series of falls in the past. Such patients may be at risk of falls in future.

Check the clinical note again and confirm if the patient presented with some complaints after the fall. If so, you can submit code R29.6. However, your physician also seems to have documented gait imbalance, so you might also consider ICD-10 code R26.9 (Unspecified abnormalities of gait and mobility).