ICD-10 Coding for History of Syncope(R55, Z86.79)
Complete ICD-10-CM coding and documentation guide for History of Syncope. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to History of Syncope
R55Primary Range
Syncope and collapse
This range includes codes for syncope and related conditions, used when syncope is the primary concern without a known etiology.
Personal history of other diseases of the circulatory system
Used for documenting a resolved history of syncope when no active management is required.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R55 | Syncope and collapse | Use when syncope is present without a known underlying cause. |
|
| Z86.79 | Personal history of other diseases of the circulatory system | Use when syncope is resolved and documented as history. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for history of syncope
Essential facts and insights about History of Syncope
Primary ICD-10-CM Codes for history of syncope
Decision Criteria
clinical Criteria
- No identifiable cause after evaluation
Applicable To
- Fainting
- Vasovagal syncope
Excludes
- Orthostatic hypotension (I95.1)
Clinical Validation Requirements
- Unexplained collapse
- Negative cardiac workup
Code-Specific Risks
- Misclassification if underlying cause is known but not documented
Coding Notes
- Ensure no underlying cause is documented before using R55 as a primary code.
Z86.79 - Personal history of other diseases of the circulatory system
Use when syncope is resolved and documented as history.
Applicable To
- History of syncope
Clinical Validation Requirements
- Documented resolution of syncope
- No current symptoms
Coding Notes
Ensure syncope is fully resolved before using this code.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Personal history of other diseases of the circulatory system
Z86.79Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Orthostatic hypotension
I95.1Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting History of Syncope to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R55.
Impact
Clinical: Misinterpretation of patient condition, Regulatory: Potential audit issues, Financial: Incorrect billing and reimbursement
Mitigation Strategy
Use specific terms, Document resolution status
Impact
Reimbursement: Potential underpayment due to incorrect DRG assignment, Compliance: Non-compliance with ICD-10 coding guidelines, Data Quality: Inaccurate patient records and statistics
Mitigation Strategy
Use R55 if syncope is still active or unresolved.
Impact
Using R55 as principal when an underlying cause is documented
Mitigation Strategy
Review documentation for underlying causes before coding
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for History of Syncope, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for History of Syncope
Use these documentation templates to ensure complete and accurate documentation for History of Syncope. These templates include all required elements for proper coding and billing.
Follow-up visit for resolved syncope
Specialty: Internal MedicineRequired Elements
- History of syncope
- Resolution status
- Current management
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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