2025 ICD-10-CM code W18.40XD
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A External causes of morbidity - Slipping, tripping, and stumbling Chapter 20: External causes of morbidity and mortality Feed
Slipping, tripping, and stumbling without falling, unspecified, subsequent encounter.
The medical necessity is established by the documentation of the event, the subsequent encounter, and any resulting symptoms or conditions requiring medical attention.Further, the documentation must show the medical necessity of using this code and other related codes.
The clinical responsibility involves documenting the event (slip, trip, or stumble), noting the absence of a fall, specifying whether this is a subsequent encounter, and recording any related injuries or conditions requiring additional codes.Accurate documentation ensures proper billing.
- Chapter 20: External causes of morbidity and mortality
- W18.40XD falls under the broader category of W18.4 (Slipping, tripping and stumbling without falling, unspecified) and the even broader category of W18 (Other slipping, tripping and stumbling and falls).
In simple words: This code is for when someone slips, trips, or stumbles but doesn't fall, and it's not the first time they've seen a doctor for this type of event.The doctor doesn't know exactly why they slipped, tripped, or stumbled.If there was an injury, the doctor will use another code to describe that too.
This ICD-10-CM code classifies instances where a patient slips, trips, or stumbles without actually falling, and this event is documented during a subsequent encounter.The code is used when the specific cause of the slip, trip, or stumble is unknown.It's crucial to note that this code is used for subsequent encounters; use the initial encounter code (W18.40XA) for the first instance of this event. This code should be used in conjunction with a code that describes any resulting injury or condition.
Example 1: A patient presents to the clinic for a follow-up visit after a previous incident where they tripped on a rug but did not fall.During this visit, they complain of continued knee pain, likely related to the previous incident.W18.40XD would be coded along with an appropriate code for the knee pain., A patient in a rehabilitation center experienced a near-fall while walking, but thankfully, managed to avoid falling.The therapist notes this incident in their report, and W18.40XD may be applied to reflect this non-fall event in a subsequent encounter., An elderly patient is seen in the emergency department for unrelated reasons, but during the physical examination, they mention repeatedly tripping at home without falling, causing some discomfort but no specific injury needing further coding.W18.40XD could be used to document this recurring event. This will be coded along with other codes representing their chief complaint.
Detailed documentation should include a description of the event, confirmation that a fall did not occur, the context of the event (e.g., location, activity), and any resulting symptoms or injuries requiring further coding.The documentation must clearly indicate this is a subsequent encounter.
** This code is specifically for subsequent encounters.If it is the first time the patient is seen for this type of event, the initial encounter code (W18.40XA) should be used. Always code any injuries or conditions that result from the event with additional codes.
- Payment Status: Active
- Specialties:Geriatrics, physical therapy, occupational therapy, family medicine, emergency medicine
- Place of Service:Office, Outpatient Hospital, Emergency Room - Hospital, Skilled Nursing Facility, Home Health