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2025 ICD-10-CM code W18.40XS

Sequela of slipping, tripping, and stumbling without falling, unspecified.

This code should always be used as a secondary code with a code from another chapter specifying the nature of the sequela.The seventh character (X, D, S, A) indicates the encounter status.

Modifiers may apply depending on the circumstances of the sequela and the services provided.

Medical necessity is established by the presence of a verifiable sequela resulting from the previous tripping incident. The documentation must clearly link the current condition to the past event. The treatment of the sequela itself must meet medical necessity guidelines.

The clinical responsibility would depend on the nature of the sequela.For example, a physician specializing in orthopedics might be responsible if the sequela is a fracture, or a neurologist if it's neurological damage.

IMPORTANT:W18.40XA (initial encounter), W18.40XD (subsequent encounter), other codes from chapters 1-18 may be needed to describe the sequela, depending on the nature of the health problem.

In simple words: This code is for long-term health problems that happened because someone slipped, tripped, or stumbled but didn't actually fall.It's used along with another code to describe the specific health problem.

This code classifies the late effects (sequelae) resulting from an incident of slipping, tripping, or stumbling that did not involve a fall.It is used to indicate that a current health condition is a consequence of a previous, unspecified slipping, tripping, or stumbling event.This code should be used in conjunction with a code from another chapter specifying the nature of the sequela.

Example 1: A patient presents with chronic pain in their lower back, a sequela of a tripping incident six months prior.The physician codes W18.40XS in conjunction with a code describing the back pain (e.g., M54.5 - Lumbago)., A patient who sustained a wrist injury from a tripping incident a year ago is experiencing persistent limited range of motion. W18.40XS is coded alongside the specific diagnosis of the wrist impairment., A patient reports ongoing knee problems following a minor tripping incident.After examination, the physician determines that the patient has developed osteoarthritis in the knee and uses W18.40XS alongside the code for osteoarthritis of the knee.

Detailed history of the tripping incident, including date, mechanism of injury, and initial treatment.Documentation of the sequela, including examination findings, diagnostic imaging (if applicable), and functional assessment.Any ongoing treatment or management of the sequela should also be well documented.

** The seventh character in this code specifies the encounter status: A = initial encounter; D = subsequent encounter; S = sequela.This code is intended for use when the specific condition resulting from the slipping, tripping, or stumbling event is documented and coded elsewhere.

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