Depending on the reason a patient is being seen after a fall, here are two scenarios to consider. Let's look at these two diagnoses - Fall, initial encounter vs. history of falls. If clinician uses the diagnosis of "Fall, initial encounter" then they need to add the date of the fall to the chart note. When using the code of W19.XXXA, a Date of Injury must be provided. Add the date of injury in the claim information record. As an example, this diagnosis can be used for worker's compensation visits. Or, if appropriate, clinician can also consider using the diagnosis of 'history of falls' Z91.81. With this code, no date is needed. This can be used with quality reporting. Clinicians documentation of the reason for the fall will help with code selection. Disclaimer: This guidance is to be used for an easy reference; the ICD-9-CM and ICD-10-CM code books and the Official Guidelines for Coding and Reporting are the authoritative references for accurate and compl...
Dementia ICD-10-CM classifies dementia on the basis of: etiology, severity and associated behavioral disturbances. Etiology refers to the type of dementia. This can include: Vascular dementia F01 Dementia in other diseases classified elsewhere F02 Unspecified dementia F03 Severity includes mild, moderate and severe: Mild - Clearly evident functional impact on daily life, affecting mainly instrumental activities. No longer fully independent; requires occasional assistance with ADLs. Moderate - Extensive functional impact on daily life with impairment in basic activities. No longer independent; requires frequent assistance with ADLs. Sev...