2025 ICD-10-CM code W18.40XA
(Active) Effective Date: N/A External causes of morbidity - Slipping, tripping, stumbling and falls 20 Feed
Slipping, tripping, and stumbling without falling, unspecified, initial encounter.
Medical necessity for using this code is established when a patient seeks medical attention or evaluation due to a near-fall event. This may be for preventative measures, injury assessment, or to address concerns about future falls.
The clinical responsibility is to document the circumstances of the near-fall, assess for any injuries, and provide appropriate care or preventative recommendations as needed.
In simple words: This code is used when someone slips, trips, or stumbles but doesn't actually fall.It's used during the first visit for this incident.
This code describes an incident where a person slips, trips, or stumbles but does not fall.It is unspecified, meaning there are no additional details about the circumstances. This is for the initial encounter.
Example 1: A patient presents to their physician's office after nearly falling due to tripping over a rug at home.They did not fall or sustain any injuries.The physician documents the event and provides recommendations for fall prevention., A patient stumbles on an uneven sidewalk while walking to work but catches themselves before falling.Concerned about future falls, they visit their doctor.The physician documents the near-fall event and assesses the patient's risk for future falls., A patient in a nursing home slips while getting out of bed but grabs onto the bed rail, preventing a fall. The nurse documents the slip and performs a fall risk assessment.This information is later relayed to the physician.
Documentation should include the circumstances of the slipping, tripping, or stumbling event, any contributing factors (e.g., uneven surface, loose rug), and any symptoms or injuries the patient experienced, even if minor.A fall risk assessment may also be necessary.
** The code W18.40XA specifically refers to the initial encounter.Subsequent encounters for the same near-fall event should be coded with W18.40XD.
- Specialties:Primary care, geriatrics, physical therapy, occupational therapy, and any specialty where fall risk assessment and prevention are relevant.
- Place of Service:Office, Home, Nursing Facility, Hospital, etc.The place of service depends on where the patient is seen for the encounter related to the near-fall event.