Ways Professionals Can Reduce Falls
Reimbursement
Fall risk evaluation and interventions for older adults may be reimbursable if they are reasonable, necessary and follow specific guidelines set forth by the payer. There are a variety of third party payers and each payer may use a different coding or billing process.
This page includes a general description of Medicare coverage and payment policies for fall risk evaluation and interventions and use of V code for history of falls.
Medicare Coverage and Policies
Medicare does not cover services labeled as preventing or controlling risk but covers services labeled as treating symptoms. An older adult who has a symptom that predisposes him or her to a fall could receive Medicare-reimbursed services. Many fall risk factors can be linked to a symptom-specific diagnostic code or an evaluation and management visit.
V Code for History of Falls
The Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) have developed a V code to identify older adults who have fallen and are predisposed to recurrent falls.
The code, V15.88, indicates that the older adult may benefit from a fall risk evaluation and management of fall risk(s).
Qualification of the Medicare V code 15.88 is based upon the presence and documentation of at least one of the following:
- Recent history of falls in last 6-12 months*
- Health-related falls risk factors*
- Health behaviors related to falls*
*Documentation qualifies for use of Medicare V code 15.88, which is a secondary ICD10 code to be used with primary ICD10 codes.
An ICD-10-CM code is required for all professional claims, e.g., physicians, non-physician practitioners, independent clinical diagnostic laboratories, occupational and physical therapists, independent diagnostic testing facilities, audiologist, ambulatory surgical centers (ASCs), and for all institutional claims.
Learn More
You can learn more about reimbursement of fall risk evaluation and management for older adults.
Centers for Disease Control and Prevention, National Center for Health Statistics, Classification of Diseases and Functioning & Disability at www.cdc.gov/nchs/icd9.htm
Centers for Medicare and Medicaid Services (CMS) at www.cms.hhs.gov/
Medicare at www.medicare.gov
Tinnetti, M., Gordon, C., Sogolow, E., Lapin, P., Bradley, E. Fall-risk evaluation and management: Challenges in adopting geriatric care practices. The Gerontologist, 2006, 46 (6), 717-725.
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