CDI Tip of the Month

OPTUM NEWSLETTER – November- Focus on Diabetes mellitus

Fall Risk Screening

Coding for fall risk screenings varies depending on whether the screening took place during an Annual Wellness Visits (AWV) or a general office visit. There are 2 CPT II codes to choose from 1100F or 1101F. CPT II code 3288F would be added along with either 1100F or 1101F to indicate a fall risk assessment was completed.

  • 1100F – Patient screened for future fall risk; documentation of 2 or more falls in the past year or any fall with injury in the past year
  • 1101F – ​Patient screened for future fall risk; documentation of no falls in the past year or only ONE fall without injury in the past year
  • ​3288F​ – indicate a fall risk assessment was completed(Should be used with either 1100F or 1101F)​

If patients are screened during an AWV, Using additional CPT II performance tracking codes on the claim, such as the 1100F code, will help indicate if the patient has documented falls in the past. To indicate that a patient has had no falls within the past year or one fall without injury, the 1101F code should be used. Additionally, the 3288F code should be used with the functional status CPT II codes (1100F, 1101F) to indicate a fall risk assessment was completed.

If the patient is seen for a general routine encounter, the specific CPT/HCPCS code used would be based on the reason for the visit and time spent with the provider. These codes can range from 99201 to 99350. The CPT II codes 1100F, 1101F and 3288F are suggested in this scenario to ensure the screening “gap” is closed, as this may be a quality performance measure. ICD-10 diagnostic codes are also suggested for any encounter, regardless of AWV, routine or physical exam encounters. These codes may vary and are applicable to the patient’s medical history and current health status at the time of the encounter, such as Z91.81 “At Risk for Falling, History of failing.”

Please reach out to Jessica Bryan at Jessica.M.Bryan@Lahey.org with questions or concerns regarding this clinical documentation tip or any other coding guidance.