CC: Family requests workup of multiple falls

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I'm really struggling with the coding of this case.

Family requests workup of the cause of patient's recent frequent falls. Patient also has multiple abrasions as a result of the recent falls.

I really can't give you much more info other than the above because there really ISN'T much more than the above. Patient presented to the ED for this workup and after CT, labs, etc., is referred back to the PCP for continued workup. Contusions and abrasions were also cleansed in the ED.

Admit dx?

Principal/additional dxs?

I'm getting many differing opinions in our office, and I really can't find anything on line.

Thanks for your help!
 

kak6

Guru
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Wouldn't you want to just code the condition the pt presented with and what the provider treated? Obviously, Contusions and abrasions, also if the pt stated they fell because of weakness, dizziness or pain? You can only code what is documented.
 

karen57

Networker
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I agree with KAK6. I might also use the E code to identify the fall; also, there is a V code that indicates a patient has frequent falls or is at risk of falling. I don't have my ICD-9 book with me but I think it's V15.88.
 
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