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2025 ICD-10-CM code W18.39

Other fall on the same level.

This code should be used as a secondary code in conjunction with a code from another chapter specifying the nature of the injury resulting from the fall (Chapter 19, Injury, poisoning and certain other consequences of external causes (S00-T88)).Appropriate 7th character for initial, subsequent, or sequela encounters should be added.

Documentation should support the medical necessity of the encounter.This could include a narrative describing the circumstances of the fall and resulting injuries, and the appropriate treatment rendered.

Documentation of the fall, patient assessment for injuries sustained, treatment of any injuries, and follow-up care as needed.

IMPORTANT:No specific alternate codes provided in the source.However, other codes within the W00-W19 range may be applicable depending on the specific circumstances of the fall.Consider reviewing the complete ICD-10-CM classification for more specific codes related to falls.

In simple words: This code is used when someone falls on a flat surface, without falling from any height or because of something specific like an assault, self-harm, or falling from a vehicle.

This code classifies a fall on the same level, excluding falls from a height or those involving other specified circumstances (e.g., assault, self-harm, falls from machinery or transport vehicles).

Example 1: A 70-year-old patient with a history of osteoporosis trips on a rug at home, falls on the same level and sustains a wrist fracture., A 30-year-old patient slips on a wet floor in a grocery store, resulting in a minor ankle sprain. , A 5-year-old child stumbles while playing and falls on the same level, resulting in a minor abrasion to the knee.

Detailed description of the fall event, including location, circumstances, and any witnesses.Complete assessment and documentation of any resulting injuries.Treatment plan and any follow-up care provided.

** This code is for falls on the same level; falls from a height are coded differently.Always ensure the most specific code possible is selected to accurately reflect the patient's condition.

** Only Enterprise users with EHR integration can access case-specific answers. Click here to request access.

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