2025 ICD-10-CM code W18.31
(Active) Effective Date: N/A Accidents (V00-X58) - Slipping, tripping, stumbling and falls (W00-W19) 20 External causes of morbidity (V00-Y99) Feed
Fall on same level due to stepping on an object. Fall on same level due to stepping on an animal.
The code W18.31 can be used with 7th character extensions to indicate the encounter type (initial encounter, subsequent encounter, sequela).For example: W18.31XA - initial encounter.Refer to official ICD-10-CM guidelines for more information.
Medical necessity is established by the need to treat the injuries resulting from the fall. This may include diagnostic tests, treatments, and follow-up care.
The clinical responsibility for this code lies in documenting the circumstances of the fall, including the object or animal stepped on, and any resulting injuries. This ensures accurate coding and subsequent treatment.
- 20 External causes of morbidity (V00-Y99)
- Accidents (V00-X58)Other external causes of accidental injury (W00-X58)Slipping, tripping, stumbling and falls (W00-W19)
In simple words: A fall on the same level caused by stepping on an object or animal.
Fall on same level due to stepping on an object. Fall on same level due to stepping on an animal. Excludes1: slipping, tripping and stumbling without fall due to stepping on animal (W18.41)
Example 1: A patient tripped and fell in their home after stepping on a toy. The patient sustained a wrist fracture., A hiker stepped on a rock while on a trail, lost their balance, and fell, resulting in a sprained ankle., A person walking their dog stepped on the dog's leash, causing them to trip and fall, resulting in a laceration to the knee.
Documentation should clearly specify the cause of the fall as stepping on an object or animal, the location of the fall (same level), and the nature of any injuries sustained.
** This code describes the external cause of the fall, not the specific injuries sustained.Always use additional codes to specify the injuries.This information is current as of 2024-11-30.
- Specialties:Emergency Medicine, Primary Care, Orthopedics
- Place of Service:Home, Office, Outpatient Hospital, Emergency Room - Hospital, Other Place of Service