Status post fall ICD 10

dbolivar1

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Albuquerque, NM
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Hello,

Is there a ICD-10 code for Status post fall?

Patient 21wks to came in to OBT after a fall (fell onto her abdomen), found to be in stable condition. An ultrasound was ordered. Should I use Z04.3 because there was no issues after monitoring for 6 hours. Or should I use the O9A.212 and S39.91xa?

Thank you in advance!
 

dbolivar1

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Albuquerque, NM
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I have another case for a fall;

29.6 wks. pregnant with two days of lower back pain. Fell on her butt, toddler knocked patient over. Denies any trauma to abdomen. Has difficulty moving certain was and sit for a long period of time. NST was done. Left in stable condition

A/P
S/P fall, no abdominal trauma
Likely musculoskeletal

Medication was prescribed - Tylenol and flexeril

Would I code this with Z04.3? Or O9A.212, S39.92xa, O99.891 and M54.50

Thank you in advance
 
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Walnut Creek, CA
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hello,
I am still learning OBGYN so please don't take my answer as 100% correct. In both cases, I would use Injury ICD-10 codes because they were injuries - falls, not motor accident. The pain associates with falls. O9A.212 is good, your code S39.92xa is for injury to the back ( I used Google, sorry, have no book with me), I would find injury to the buttock if there is such. I would skip O99.891 because the auditor might think that pt has additional issue -pain related to something else.
 
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