E888.9 vs. E885.9

sleepycats

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The ER report states "the patient slipped and fell on the ice", that is the only information given regarding the fall. I think E888.9 should be coded since the patient could have slipped on the ice walking down porch steps, exiting a car, etc. My coordinator feels E885.9 should be coded. I feel this is incorrect as the E885 heading states "on the same level". She states E885.9 Fall from slipping, tripping or stumbling is correct since we can only code what is documented, therefore because the patient slipped E885.9 is correct. I feel that you are then assuming it was a fall on the same level. Feedback, rationales, etc. would be appreciated. Thanks in advance!!:)
 

Grintwig

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I personally would go with E888.9 because there is so little information there and the code E885.9 does specify "one level" which the ER report does not state.
Of course I am by no means an expert.
 
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