Use of International Classification of Diseases, Ninth Revision, Clinical Modification, codes to identify inpatient fall-related injuries.

Waters TM1, Chandler AM, Mion LC, Daniels MJ, Kessler LA, Miller ST, Shorr RI.

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Abstract

OBJECTIVES:

To compare falls and fall-related injuries that a fall evaluator or hospital incident report identified with injuries identified according to discharge International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for the same set of inpatient episodes of care.

DESIGN:

Prospective, descriptive study.

SETTING:

Sixteen adult general medical and surgical units in a major urban teaching hospital.

PARTICIPANTS:

All adults who sustained a fall with injury during a 5-year period (380 falls with injury).

MEASUREMENTS:

Falls that a fall evaluator or hospital incident report identified were classified according to their injury severity. Discharge abstracts provided diagnosis codes (ICD-9-CM) for the discharge, including fall-related injury codes.

RESULTS:

Three hundred forty-three inpatient falls with injury (90.2%) resulted in temporary harm to the individual; the remaining 37 falls (9.8%) resulted in more-serious harm. Sixteen of the 37 falls with injury extending hospitalization or resulting in death were identified using Centers for Medicare and Medicaid Services (CMS)-targeted injury code ranges combined with present-on-admission indicators. Of the 21 falls with injury that were not identified, nine (42.9%) lacked documentation of any injury, and seven (33.3%) identified other injuries outside the CMS-targeted injury code ranges.