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Reporting a fall without an injury

  1. Default Reporting a fall without an injury
    Medical Coding Books
    I was wondering if anyone could help me clarify if in order to code a fall I must have an injury. A PT fell in the hospital but was recorded that no injury occurred. Should I still report the fall using an E code, E8889 and E8497. Can I do that or I must have a diagnoses before coding an ecode? Thanks.
    Jessica Martinez, CCS, CPC

  2. #2
    Columbia, MO
    E codes can never be first or only diagnosis codes. If the patient was examined and it is determined that no injury occured then use V71.4 for observation following other accident with nothing found followed by the E codes.

    Debra A. Mitchell, MSPH, CPC-H

  3. Default
    Thank you Debra! So you are saying that E codes cannot be used alone, they must have a Dx to go with them. Got it!
    I have a question in regards to the code V71.4 - The case I'm coding is an inpatient case in a psychiatric hospital. The PDx was Major Depression Disorder. The PT also had other medical issues but during the stay here she fell. The nurses documented that there was no injury and the Physician also documented no injury. So, my question is if it's still okay to use this v code for this scenario. The book I have has a "tip" note that says: Assign observation codes only as principal/first-listed diagnosis and only if there is no documentation of any sign or symptoms. - Is this saying to use these v codes only for principal dx? Sometimes the notes on this book really cofuse me.
    Jessica Martinez, CCS, CPC

  4. #4
    Columbia, MO
    yes V71 codes are only first listed. If this is an inpatient and you are coding for the facility then this will probably not be on the discharge summary and not be coded as a part of the hospitalization at all. If you are coding for the physician then for the day of the incident this would be the first listed code.

    Debra A. Mitchell, MSPH, CPC-H

  5. Default
    Thank you so much again! I'm coding for the facility so I guess I dont have to worry about it!
    Jessica Martinez, CCS, CPC

  6. #6
    Columbia, MO
    That is how I would look at it... several things occur during an admission that have no bearing on a patients status. You always look to the discharge summary for the codes for inpatient, if this is a long term admission then you might be submitting interval bills but I still do not see this as an issue for an interim bill. Unless it affected the discharge or caused the stay to be longer or somehow changed the circumstances of the admission, we did not code it for our admissions, as these issues never appeared on the discharge summary.

    Debra A. Mitchell, MSPH, CPC-H

  7. Default
    It would be great if I was coding from discharge summary but unfortunately I have to code from the chart alone. Discharge summaries are not ready until almost 30 days after discharge date! I have to code each case no later than 3 days after discharge date; so I have struggle with the doctor's writing and nurses! In this facility they do interval bills but the only thing they require from me is entering the PDX into the system and nothing else, I don't even see the chart at that time. They give me the PDX and that's what I enter - but when I finally get the charge and review everything if necessary I can change the PDX based on documentation found when coding a case. I'm not sure about how a few things are done in this facility… - but then again this is my first job as a coder!

    Going back to this case, yes, I don't think the fall affected the stay or changed the circumstances of admission. Thank you for your explanation it helps a lot when someone else explains things instead of just going in circles in my mind. haha
    Jessica Martinez, CCS, CPC

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