Wiki Fall with no diagnosis

[karawat23]

What will be the best code for fall with no diagnosis found and also the fall is not witnessed by anyone

Reason of visit: Fall

DX: Fall

 

[mitchellde]

What will be the best code for fall with no diagnosis found and also the fall is not witnessed by anyone

Reason of visit: Fall

DX: Fall

If the documentation supports no injury found then use a V 71 code for injury not found.

 

[OCD_coder]

You can also use symptoms (pain) or findings in the HPI or Exam, such as abnormal gait. or lack of coordination. V15.88 Personal Hx of fall also is acceptable and payers get a little more information.

I do agree that V71 could be correct if no injury were documented.