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ICD-10-CM code Z91.81 (History of falling) can be used to document a patient’s prior falls that are affecting or influencing the patient’s current care. In order to use the code properly, a provider must document properly, and falls must be coded in the correct order, that is, falls must be coded as a secondary diagnosis. Accurate coding offers support, reimbursement, and lessens the chances of a compliance issue. Knowing the basics of documentation, billing guidelines, and errors will aid in ensuring accurate reporting and improving patient safety.
Patients, especially, older people and people with mobility, neuro, and balance disorders, have a high risk of falling. They may not suffer an injury with the first fall, but once a history of falling is established, the risk of subsequent falls, and even hospitalizations, and other adverse events increases. In medical billing, an important aspect to completing the risk adjustment, preventive care planning, and the overall payment is documenting a patient’s history of falls. In this aspect, the ICD-10-CM code Z91.81 (History of falling) is especially important. This blog will elaborate on Z91.81 and its important facets, such as coding guidelines, requirements, order of codes, and billing concerns.
Understanding ICD-10 Code Z91.81
The ICD-10-CM code Z91.81, “History of falling”, is classified under Chapter 21 of the ICD 10-CM codes as a *”Factors influencing health status and contact with health services (Z00–Z99)”*. This code captures the fact that a patient has fallen before, and even though no injury is present at the time of assessment, the patient is at risk for falls. It is important to note that Z91.81 is not applicable for a patient who is currently experiencing injuries from falling. It is a code that reflects a prior injury and continues to impact clinical decision-making. Because of this code, the clinician is able to put a fall prevention strategy in place, and the payer knows this patient is at risk.
Clinical Importance of Documenting History of Falling
Managing patients that fall is very important as patients that fall often require balance assessments, reviews of medications, and referrals to physical therapy, as well as home safety evaluations and mobility aids. The Z91.81 is important as it will show the risk factor in the documentation and in the claims data. The Z91.81 in population health is important as it leads to better health in the community and greater potential to allocate funds to patients that fall often.
Clinical Importance of Documenting When to Use ICD-10 Code Z91.81
Clinical Importance of Documenting Use in Routine and Preventive Visits
Z91.81 is often used in the annual wellness visit reports, in preventive visits, and in assessments of the elderly, when the provider writes a note explaining a past fall. For example, it is a requirement of the Golden Medicare Program and the providers are required to perform a fall and risk of fall screening. If the patient has a history of falls, and the provider writes it down, Z91.81 must be used.
Use in Chronic Disease Management
Patients with Parkinson’s disease, stroke, peripheral neuropathy, osteoporosis, and other balance disorders may have an increased risk of falling. If the documentation indicates that the patient has had falls that have a bearing on the current course of treatment, Z91.81 may be used. Coders, however, have to be certain that the fall is an old one and not a new fall. If the patient is coming in as a result of a new fall, then an injury code and the relevant external cause codes have to be assigned.
Clinical Importance of Documenting Documentation Requirements
The integrity of the documentation has an impact on the accuracy of the coding and payment. The provider has to explicitly state that the patient has a “**history of falling”**. This is something that coders have to be able to take, not guess, from the documentation.
Provider Comments
The provider statement must document evidence of prior falling risk such as “History of falls,” “Patient reports multiple falls in the past year,” “High fall risk due to prior falls,” etc. If the provider statement is missing evidence of prior falls, it is considered unsupported coding to assign ICD-10-CM code Z91.81. Compliance reviews and audits may not support this, and it may lead to a reimbursement denial.
Timeframe & Relevance
ICD-10-CM does not indicate rigid timelines, but it should be documented that the history of falling is clinically relevant. Practitioners should ideally note when the fall(s) took place, how often they occurred, and if any injuries were sustained. Additionally, they should note any current prevention strategies, such as the use of assistive devices, therapy, and home safety modifications.
Impact of Current Care
When documenting a patient’s falls history, you may need to explain how this falls history justifies the need for physical therapy, an assistive device, medication changes, or home safety instruction. If the documentation shows medical necessity, relevance, and impact on the patient’s care, then defending the case during audits and reimbursement reviews becomes a lot less challenging.
Coding Guidelines and Rules of Sequencing
Z91.81 as Secondary Code
Z91.81 is an example of a secondary diagnosis that does not stand by itself to justify the visit. For example, Z91.81 can be an additional code if a patient being treated for hypertension, and falls that are documented and are affecting decision making, are covered by the additional code.
Using Injury Codes with Z91.81
Z91.81 cannot be used for falls, and if a patient falls and breaks their leg, the coders need to include the code for the leg injury, code for the injury caused by falling (e.g. W19.XXXA) or any other codes they see fit. Z91.81 can still be used by coders if falls have happened in the past but are unrelated to the current situation.
Related and Excluded Codes
Coders should carefully review ICD-10-CM guidelines and instructional notes. Z91.81 does not stand in for the code of personal history of other injuries and other codes like current accidental fall, syncope or collapse (R55). The right code selection means compliance and avoidance of claim denials.
Billing and Reimbursement
Medical Necessity Support
Services related to Z91.81 that would be considered medically needed are therapy (occupational, physical), medical aid ( Walkers/canes ) and home assist A history of falls is a risk for the patient, and documentation may be needed to show preventative measures in order to get reimbursed.
Risk Adjustment and Quality Reporting
With Value-Based Care and the Medicare Advantage Program, Z91.81 may not by itself map to an HCC, but it still impacts a patient’s risk profile. Correct reporting improves metrics, strengthens coordinated care, and reduces readmissions. Not capturing the pertinent Z codes may understate a patient’s complexity and cause the reimbursement to be inaccurate.
Strategies to Avoid Billing Errors
With Value-Based Care and the Medicare Advantage Program, Z91.81 may not by itself map to an HCC, but it still impacts a patient’s risk profile. Correct reporting improves metrics, strengthens coordinated care, and reduces readmissions. Not capturing the pertinent Z codes may understate a patient’s complexity and cause the reimbursement to be inaccurate.
Audit Readiness and Compliance
Healthcare institutions need to support Z91.81 along with its valid justification. Documentation with clinical rationale is important for the justification of Z91.81 so that a payer’s rationale for an audit aligns with the following:
- The fall history was documented by the credentialed provider.
- The history influenced the fall risk assessment leading to a change in the fall risk treatment.
- The code was sequenced in the correct order.
Coding staff and provider education focusing on compliance to audit strategies along with routine audits demonstrate risk compliance to the Z91.81 explanation.
Protective Care Coding
The accurate coding of fall history is crucial in implementing effective protective care. The problem of falling and subsequent injury becomes acute in older adults leading to increased hospitalizations. Fall history is coded along with Z91.81 to divert the focus to proactive care. Balanced exercise and strength exercises along with an assessment of current medications and fall risk due to the environment are examples of protective care that, along with correct coding, should ensure payment.
Conclusion
When clinicians know how to use the ICD-10-CM code **Z91.81 (History of falling)**, they can incorporate this code to document patient risk while helping develop strategies with a focus on prevention. Z91.81, by itself, is not a code that represents an injury but rather tells a clinician that there is a potential risk that can affect clinical management as well as the reimbursement. Proper documentation by the provider, accurate sequencing, and proper use of the coding guidelines is a must in achieving compliance and preventing claim denials. Knowledge of its use will positively impact the quality of reporting and the safety of the patient.
Make An Appintment With A2ZFAQs
The code Z91.81 means there is “an *documented history of falling.” This means the patient has previously fallen and is considered by the provider to be at risk to be injured by falling again. This code is used when the history of the falling impacts the care that is being given to the patient, and it is not used to document an active fall or injury.
The answer is no. Z91.81 is not used for an active fall or injury. If the history of falling is applied to a patient after a fall, the coder is required to code the injury first and the external cause code next and Z91.81 can be added if the history of falling is documented.
Z91.81 is generally a secondary diagnosis code. It explains the primary diagnosis code and the reason for the encounter; however, it is not typically the reason for the visit, unless it is documented to be that.
The patient’s record should have documentation from the provider that the patient has a history of falling. If fall risk assessments were completed, if counseling for prevention was documented, and if there was a referral to therapy, that should also be in the documentation. If they only document the fall and the counseling, that may be the only documentation.
Z91.81 does help support medical necessity regarding the Preventive Services such as Physical Therapy, Mobility Devices, and Home Health services. Z91.81 itself may not always carry direct risk adjustment weight, but it helps with the overall reporting of risk adjustment and quality measures for the patient.