Health Information Management

Falls, spills, and other uncodable events 

Briefings on Coding Compliance Strategies, February 1, 2009

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Seek clarification regarding etiology 

by Robert S. Gold, MD 

Patient falls account for nearly a half-million inpatient days spent in the hospital each year, making them quite costly to those hospitals and to the healthcare industry as a whole. In addition, the mortality rate related to patient falls is 7%–20%.  

The reason patients fall isn’t always straightforward. Falls can occur because of disease or musculoskeletal processes or malnutrition. Some falls result from syncopal episodes (i.e., temporary loss of consciousness). Some indicate an underlying pathology. Others simply result from a patient’s inability to easily move around. In most cases, patients who fall risk injury-related morbidity or mortality. 

To provide appropriate treatment, physicians must be aware of the multitude of diagnoses associated with falls. Typically, a fall is a symptom, not a diagnosis, so it’s important to discover the causes behind the ailment. Let’s look at a scenario.

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