Find comprehensive information on Postural Orthostatic Tachycardia Syndrome (POTS) diagnosis, including clinical documentation requirements, ICD-10 codes (I49.81, G90.84), medical coding guidelines, and healthcare provider resources. Learn about POTS symptoms, treatment options, and differential diagnosis considerations for accurate clinical evaluation and improved patient care. This resource offers guidance for healthcare professionals on effectively documenting and coding POTS cases in medical records.
Also known as
Other circulatory diseases
Covers various circulatory disorders, including POTS which often lacks a specific code.
Other disorders of nervous system
May be used for POTS if neurogenic causes are suspected or prominent.
Syncope and collapse
Relates to common POTS symptoms like fainting or lightheadedness.
Follow this step-by-step guide to choose the correct ICD-10 code.
Does patient meet diagnostic criteria for POTS?
Yes
Is there a known secondary cause?
No
Do not code POTS. Code signs/symptoms.
When to use each related code
| Description |
|---|
| Postural Orthostatic Tachycardia Syndrome |
| Orthostatic Hypotension |
| Vasovagal Syncope |
Using unspecified codes like R00.2 (syncope and collapse) when more specific POTS codes (e.g., G90.8-, I95.1-) are applicable, impacting reimbursement and data accuracy.
Incorrectly coding overlapping symptoms (e.g., orthostatic hypotension, tachycardia) separately from POTS, leading to overcoding and compliance issues.
Insufficient clinical documentation to justify POTS diagnosis (e.g., tilt table test results), increasing audit risk and potential claim denials.
Patient presents with symptoms suggestive of Postural Orthostatic Tachycardia Syndrome (POTS). Key symptoms reported include orthostatic intolerance, lightheadedness, dizziness, palpitations, tachycardia, and near syncope upon standing or with prolonged upright posture. Pre-syncopal symptoms may also include blurred vision, weakness, fatigue, and brain fog. Symptoms are often exacerbated by heat, exertion, dehydration, and meals. The patient denies chest pain, shortness of breath, and loss of consciousness. On examination, heart rate increases significantly upon standing, consistent with the diagnostic criteria for POTS. Blood pressure remains stable or exhibits only mild orthostatic hypotension. A thorough review of systems was conducted, including cardiac, neurological, and endocrine evaluations, to rule out other potential causes of orthostatic intolerance such as orthostatic hypotension, vasovagal syncope, and secondary dysautonomia. Initial diagnostic workup includes a complete blood count (CBC), comprehensive metabolic panel (CMP), thyroid stimulating hormone (TSH) level, and electrocardiogram (ECG). Differential diagnoses include inappropriate sinus tachycardia, deconditioning, anxiety disorders, and other forms of orthostatic intolerance. Patient education regarding lifestyle modifications, including increased fluid and salt intake, compression stockings, and graded exercise therapy, has been initiated. Follow-up appointment scheduled to assess response to conservative management and consider further evaluation including tilt table testing if symptoms persist. ICD-10 code G90.84 (Orthostatic hypotension) is used for billing purposes, as there is no specific ICD-10 code for POTS. Medical billing for POTS often involves coding for the presenting symptoms and associated diagnostic testing.