Neurology & Pain Management Coding Alert

Double check notes before falling for easy answers.The neurologist wrote "frequent falls" on a patient's chart, so now you're faced with choosing the best diagnosis code. Answer these three questions to narrow the options.Question 1: Is This a New Problem? Your first step in assigning a diagnosis is to verify whether the patient has an extended history of frequent falls."I've seen my doctors refer in the HPI that the patient has had frequent falls, which indicates deviation from the norm for the patient," says Vonda Pickelsimer, a coder with Neurology Associates of Greenville, S.C. "Sometimes they note injuries due to the fall, such as superficial injuries, lacerations, or broken bones."If the neurologist verifies a history of falls, add V15.88 (Other specified personal history presenting hazards to health; history of fall). Note that ICD-9 explanations specify that V15.88 also applies to "at risk for falling.""Typically, the neurologist would elicit the history [...]