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2025 ICD-10-CM code W18.2

Fall in (into) a shower or empty bathtub.

Always use additional codes to specify the nature and extent of any resulting injuries.The seventh character (A, D, or S) must be appended to the code to indicate the encounter type:A=initial encounter, D=subsequent encounter, S=sequela.

Modifiers may be applicable depending on the circumstances of the fall and the subsequent treatment. For example, modifiers may be used to indicate the location or type of service provided.

The medical necessity would be established by the presence of injuries requiring medical attention following the fall.Documentation must support the clinical indication for treatment.

The clinical responsibility involves assessing the patient for injuries sustained from the fall, providing appropriate treatment, and documenting the event and resulting injuries.

IMPORTANT:Other codes may be necessary to describe the resulting injuries from the fall.W16.21- should be used for falls in a full bathtub causing drowning or submersion.

In simple words: A fall that happened in the shower or an empty bathtub.This code describes where the fall happened, not the injuries from the fall.

This code classifies a fall that occurs within a shower or an empty bathtub.It is used to indicate the circumstance of the injury, not the nature of the injury itself.Excludes falls in a full bathtub resulting in drowning or submersion (coded elsewhere).

Example 1: A 70-year-old female patient slips and falls in her shower, resulting in a fractured hip and a concussion.W18.2 would be coded, along with codes for the fracture and concussion., A 35-year-old male patient trips and falls in an empty bathtub while reaching for a towel, sustaining a minor laceration to his knee.W18.2 would be coded, along with a code for the laceration., A 5-year-old child falls in an empty bathtub while playing, sustaining minor abrasions.W18.2 would be used along with codes for the abrasions.

Detailed documentation of the fall including location (shower or empty bathtub), mechanism of fall (slip, trip), injuries sustained, and treatment provided.Physician's notes and any imaging reports should be included.

** This code is for falls in a shower or empty bathtub only.Falls in a full bathtub with submersion are coded differently.

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