ICD-10 Coding for Syncope and Collapse(R55, I44.2)
Complete ICD-10-CM coding and documentation guide for Syncope and Collapse. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Syncope and Collapse
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 unexplained and no other specific condition is identified. |
|
| I44.2 | Complete heart block | Use when syncope is due to confirmed AV block. |
|
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 syncope and collapse
Essential facts and insights about Syncope and Collapse
Primary ICD-10-CM Codes for syncope and collapse
Decision Criteria
clinical Criteria
- Transient loss of consciousness with spontaneous recovery.
coding Criteria
- No other specific condition identified as the cause of syncope.
Applicable To
- Fainting
- Blackout
Clinical Validation Requirements
- Transient loss of consciousness (TLOC) <1 min
- Spontaneous recovery
- No structural heart disease
Code-Specific Risks
- Misuse with conditions like orthostatic hypotension or carotid sinus syncope.
Coding Notes
- Ensure documentation specifies the absence of excluded conditions.
I44.2 - Complete heart block
Use when syncope is due to confirmed AV block.
Clinical Validation Requirements
- ECG showing complete heart block
- Pacemaker dependence
Coding Notes
Ensure ECG findings are documented.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Unconsciousness, not otherwise specified
R40.2Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Syncope and Collapse to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R55.
Impact
Clinical: May lead to misdiagnosis., Regulatory: Non-compliance with coding guidelines., Financial: Potential claim denials.
Mitigation Strategy
Use structured templates for documentation., Ensure all relevant clinical details are captured.
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Violates ICD-10 Excludes1 note., Data Quality: Leads to inaccurate clinical data.
Mitigation Strategy
Use I95.1 alone if orthostatic hypotension is confirmed.
Impact
High risk of audit if R55 is used with conditions like orthostatic hypotension.
Mitigation Strategy
Regular training on Excludes1 notes and proper documentation.
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 Syncope and Collapse, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Syncope and Collapse
Use these documentation templates to ensure complete and accurate documentation for Syncope and Collapse. These templates include all required elements for proper coding and billing.
Emergency Department Visit for Syncope
Specialty: Emergency MedicineRequired Elements
- History of Present Illness
- Physical Examination
- Diagnostic Tests
- Assessment and Plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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