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2025 ICD-10-CM code W18.31XD

Fall on same level due to stepping on an object, subsequent encounter.

This code should be used as a secondary code to the code describing the injury or condition resulting from the fall. The seventh character 'D' indicates a subsequent encounter, meaning this code should only be used for encounters after the initial treatment for the fall injury.

The subsequent encounter is medically necessary for the continued evaluation and management of the injuries sustained during the fall.This may include monitoring healing, assessing for complications, adjusting treatment plans, and providing ongoing support and rehabilitation.

Documenting the circumstances of the fall, assessing injuries, and providing or recommending appropriate treatment and follow-up care.

In simple words: A follow-up visit for a fall on the same level caused by stepping on an object.

Fall on same level due to stepping on an object, subsequent encounter.

Example 1: A patient returns for a follow-up visit after tripping over a toy at home and spraining their ankle., A patient presents for a second visit to check the healing progress of a wrist fracture sustained from falling over a rock on a hiking trail., An individual visits the clinic for a scheduled check-up after tripping on an uneven sidewalk and suffering a minor head injury.

Details of the fall, including date, time, location, cause, and the object involved. Description of any injuries or symptoms resulting from the fall. Treatment provided or recommended, including medications, therapies, and referrals.

** Excludes1: assault involving a fall (Y01-Y02), fall from animal (V80.-), fall (in) (from) machinery (in operation) (W28-W31), fall (in) (from) transport vehicle (V01-V99), intentional self-harm involving a fall (X80-X81). Excludes2: at risk for fall (history of fall) Z91.81, fall (in) (from) burning building (X00.-), fall into fire (X00-X04, X08)

  • Payment Status: Non-Billable/Non-Specific Code
  • Specialties:Emergency Medicine, Family Medicine, Internal Medicine, Orthopedics, Physical Therapy
  • Place of Service:Office, Home, Inpatient Hospital, On Campus-Outpatient Hospital,Emergency Room - Hospital,Urgent Care Facility,Other Place of Service
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