Understanding near syncope diagnosis, symptoms, and treatment is crucial for accurate clinical documentation and medical coding. This resource provides information on near syncope differential diagnosis, ICD-10 codes for near syncope (R55), pre-syncope symptoms, syncope vs. near syncope, and managing near syncope episodes in healthcare settings. Learn about evaluating syncope and near syncope, including diagnostic criteria and appropriate medical coding guidelines for precise healthcare documentation.
Also known as
Syncope and collapse
Includes codes for various types of syncope and collapse, including near syncope.
Hypotension
Low blood pressure can sometimes cause near syncope.
Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified
This broad category might include near syncope if a more specific cause cannot be identified.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is syncope documented?
Yes
Do NOT code near syncope. Code the specific type of syncope (e.g., R55).
No
Is presyncope/near syncope clearly documented?
When to use each related code
| Description |
|---|
| Near fainting, no loss of consciousness |
| Actual fainting, brief loss of consciousness |
| Dizziness, unspecified reason |
Coding Near Syncope as R55 (Syncope and Collapse) without specifying cause risks inaccurate severity and reimbursement.
Miscoding orthostatic hypotension (I95.1) as Near Syncope (R55) leads to underreporting of a specific diagnosis and impacts quality metrics.
Vague documentation lacking specific symptoms or triggers for Near Syncope makes accurate coding challenging and increases audit risk.
Patient presents with a near syncopal episode, or presyncope, characterized by a sensation of impending loss of consciousness without actual loss of consciousness. The patient described feeling lightheaded, dizzy, and weak, experiencing visual blurring or dimming, and possibly nausea. No reported loss of postural tone, seizure activity, or head trauma. Onset of symptoms was (suddengradual) and lasted approximately (duration). Precipitating factors may include prolonged standing, exertion, dehydration, emotional stress, or a change in posture. The patient denies chest pain, palpitations, shortness of breath, or focal neurological deficits. Vital signs at the time of evaluation include blood pressure (BP) (reading) and heart rate (HR) (reading). Physical examination revealed (normalabnormal) findings. Differential diagnosis includes orthostatic hypotension, vasovagal syncope, cardiac arrhythmia, dehydration, anemia, and hypoglycemia. Ordered labs include complete blood count (CBC), basic metabolic panel (BMP), electrocardiogram (ECG), and possibly further cardiac workup if indicated. Patient education provided regarding potential causes of near syncope, preventative measures such as adequate hydration and slow postural changes, and instructions to return if symptoms worsen or recur. Plan to follow up with patient (timeframe) to review test results and discuss further management. ICD-10 code R55 used for near syncope. Medical billing codes will reflect evaluation and management (E/M) services and any diagnostic testing performed.