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Patient screened for future fall risk; documentation of no falls in the past year or only 1 fall without injury in the past year (GER)

CPT4 code

Name of the Procedure:

Fall Risk Screening (GER: Geriatric Fall Risk Screening)


Fall Risk Screening is a method used to determine the likelihood of a patient experiencing a fall in the future. This particular screening focuses on identifying patients who have not experienced any falls in the past year or have had only one fall without injury within that time frame.


This procedure is designed to identify older adults who may be at risk of falling, which is crucial for implementing preventative measures. The goal is to reduce the incidence of falls and related injuries, improving overall safety and quality of life for the patient.


  • Older adults, typically age 65 or above.
  • Individuals who have not had any falls in the past year.
  • Individuals who may have experienced only one fall without injury in the past year.
  • Patients demonstrating no current gait or balance issues.


  • No specific preparations or fasting required.
  • Patients should wear comfortable, non-slip shoes for any balance tests.
  • Healthcare provider may review the patient's medical history, including any medications that could affect balance.

Procedure Description

  1. Initial Assessment:

    • Review the patient's fall history.
    • Conduct a brief interview to identify any history of falls or near-misses.
  2. Physical Evaluation:

    • Perform a basic physical assessment to check balance, gait, and strength.
    • Use tools like the Timed Up and Go (TUG) test or other balance tests.
  3. Documentation:

    • Record findings indicating no falls or only one fall without injury in the past year.
    • Update the patient's medical record accordingly.


The procedure typically takes about 15-30 minutes, depending on the thoroughness of the assessment.


This procedure is typically performed in an outpatient clinic, primary care office, or a geriatric department.


  • Primary care physician or geriatric specialist
  • Registered nurse or physician assistant
  • Physical therapist (if a detailed balance assessment is required)

Risks and Complications

There are minimal or no risks associated with the fall risk screening itself. However, failure to identify fall risk can lead to potential harm from future falls.


  • Early identification of fall risk can lead to timely interventions.
  • Helps in planning preventive strategies to reduce fall risk.
  • Improves patient's overall safety and quality of life.


There is no recovery period since this is a non-invasive screening. Patients may receive recommendations for follow-up or preventive measures if a risk is identified.


  • Comprehensive geriatric assessment.
  • Use of wearable fall detection devices.
  • Home environment assessments by occupational therapists.

Each alternative has its own set of benefits and limitations, which should be discussed with healthcare providers to determine the best approach for the individual patient.

Patient Experience

Patients should expect a straightforward and non-invasive process. They may feel reassured by the proactive approach toward their health and safety. Some might experience mild apprehension if balance issues are discovered, but healthcare providers will offer guidance and support.

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