Patient presents for implantable loop recorder (ILR) insertion for evaluation of syncope, presyncope, palpitations, or atypical chest pain.  Symptoms include (document specific patient symptoms such as lightheadedness, dizziness, shortness of breath, or loss of consciousness).  Frequency and duration of symptoms were discussed.  Patient denies any history of sustained ventricular tachycardia or ventricular fibrillation.  Electrocardiogram (ECG) today (describe findings, e.g., normal sinus rhythm, or any abnormalities).  Prior cardiac workup includes (list prior tests such as Holter monitor, echocardiogram, stress test, and results).  Risks and benefits of ILR implantation, including infection, bleeding, hematoma, and device malfunction, were explained to the patient.  Informed consent was obtained.  Pre-operative assessment completed.  Patient deemed appropriate candidate for ILR implantation for diagnostic monitoring of cardiac rhythm.  Procedure scheduled.  Diagnosis: Syncope, unspecified (or other appropriate diagnosis such as palpitations or atypical chest pain depending on the primary symptom).  ICD-10 code: R55 (or appropriate ICD-10 code for primary symptom).  CPT codes for insertion will be documented at the time of the procedure (e.g., 33282, 33283).


Patient underwent successful subcutaneous implantation of an implantable loop recorder (ILR) for continuous cardiac monitoring.  The procedure was performed under local anesthesia.  The device was placed in the left parasternal area (or specify location).  The device was interrogated and proper function confirmed.  Post-procedure ECG obtained and compared to baseline.  Hemostasis achieved.  Wound dressed.  Patient tolerated the procedure well and was discharged home in stable condition with post-operative instructions.  Diagnosis: Syncope, unspecified (or other appropriate diagnosis).  ICD-10 code: R55 (or appropriate ICD-10 code).  CPT codes: (Document appropriate codes used for the procedure).


Patient presents for follow-up after implantable loop recorder (ILR) implantation.  Device interrogated, and data reviewed.  (Describe findings, e.g., no significant arrhythmias detected, or specific arrhythmias documented).  Correlate ILR findings with patient symptoms.  Patient reports (describe patient experience with the device and any ongoing symptoms).  Plan: (Outline plan, e.g., continue ILR monitoring, medication adjustment, or further investigation).  Patient education provided regarding device function and symptom logging.  Diagnosis:  (Document primary diagnosis based on ILR findings and symptoms. Examples:  Paroxysmal atrial fibrillation, Syncope, Vasovagal syncope).  ICD-10 code: (Use appropriate code based on confirmed diagnosis, e.g., I48.0 for paroxysmal atrial fibrillation, R55 for syncope).  CPT code for device interrogation:  (Use appropriate remote or in-office interrogation code).