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2025 ICD-10-CM code W18.41

Slipping, tripping, and stumbling without falling due to stepping on an object.

Use this code only when the patient slips, trips, or stumbles without falling, and the cause is directly related to stepping on an object.Always use an additional code to specify the nature of the condition (if any) and the cause if applicable.Refer to the official ICD-10-CM guidelines for complete coding instructions.

Documentation of the incident and any resulting injuries or treatment is necessary for appropriate coding. This ensures accurate billing and tracking of healthcare utilization for safety improvements and research purposes.

Documentation of the circumstances surrounding the incident, including the type of object stepped on and any resulting injuries or conditions.The physician's role is to assess the patient for any injuries, provide appropriate treatment, and accurately document the findings.

IMPORTANT:This code should not be used if the fall occurred due to an assault (Y01-Y02), intentional self-harm (X80-X81), a fall from an animal (V80.-), a fall from machinery (W28-W31), a fall from a transport vehicle (V01-V99), or a fall in a burning building (X00.-).If a fall did occur, use the appropriate code for the fall and resulting injury.If the incident involved a collision with another person without a fall, code W51 should be used instead.

In simple words: This code describes a situation where someone slips, trips, or stumbles because they stepped on something, but they didn't actually fall.

This ICD-10-CM code classifies incidents where an individual slips, trips, or stumbles without actually falling to the ground. The cause of the incident is specifically attributed to stepping on an object.This code is used as a secondary code, typically in conjunction with a code from another chapter detailing the resulting injury or condition (if any).

Example 1: A patient steps on a loose floor tile in a hospital hallway, causing them to stumble but not fall.They report no injuries.Code W18.41 is used as a secondary code to document the incident., A construction worker steps on a nail while walking across a job site, causing them to stumble and nearly fall, but no injuries result.Code W18.41 is recorded., A patient trips over a rug at home and does not fall. A physical examination revealed no injuries.W18.41 is added to the record as a secondary code to provide context regarding the near-miss event.

Detailed description of the incident, including the type of object stepped on, the location of the incident, and any witness accounts.If any injuries occurred, these must also be thoroughly documented.

** While this code focuses on incidents where a fall did not occur, it's crucial to carefully evaluate the patient for potential injuries or delayed consequences.Even seemingly minor incidents can lead to problems later.

  • Payment Status: Active
  • Specialties:Emergency Medicine, Occupational Medicine, Family Medicine
  • Place of Service:Office, Emergency Room - Hospital, Urgent Care Facility, Other Place of Service
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