Find information on syncopal episode diagnosis, including clinical documentation, medical coding (ICD-10 R55), differential diagnosis, and treatment. This resource covers symptoms, causes of syncope, pre-syncope, near syncope, and vasovagal syncope, along with relevant healthcare guidelines for accurate and efficient clinical practice. Learn about evaluating syncope, including diagnostic tests and workup for proper medical coding and documentation.
Also known as
Syncope and collapse
Covers various types of syncope, including vasovagal and orthostatic.
Hypotension
Low blood pressure, a common cause of syncope.
Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified
May be used for syncope if a more specific cause cannot be determined.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is syncope clearly due to an underlying medical condition?
Yes
Is it due to orthostatic hypotension?
No
Is it a Vasovagal Syncope?
When to use each related code
| Description |
|---|
| Temporary loss of consciousness due to reduced blood flow to brain. |
| Orthostatic hypotension leading to syncope. |
| Vasovagal syncope triggered by emotional or physical stress. |
Coding R55 (Syncope) without specifying cause (e.g., orthostatic, cardiac) leads to lower reimbursement and data inaccuracy.
Miscoding pre-syncope (near-fainting) as true syncope (loss of consciousness) can inflate syncope rates and skew quality metrics.
Failing to code contributing conditions (e.g., dehydration, arrhythmia) with syncope impacts risk adjustment and patient care.
Patient presented with a syncopal episode, characterized by a transient loss of consciousness (TLOC) and postural tone, with spontaneous recovery. Onset of syncope was [sudden/gradual], and the duration was approximately [duration]. Preceding symptoms included [list symptoms e.g., lightheadedness, dizziness, nausea, diaphoresis, palpitations, visual disturbances, tinnitus, pallor]. No seizure-like activity observed. Post-syncopal symptoms included [list symptoms e.g., confusion, fatigue, headache, muscle weakness]. Patient denies any history of [relevant medical history e.g., seizures, cardiac disease, head trauma]. Current medications include [list medications]. Vital signs upon examination were: blood pressure [systolic]/[diastolic] mmHg, heart rate [rate] bpm, respiratory rate [rate] breaths per minute, and oxygen saturation [percentage] on room air. Physical examination revealed [relevant findings e.g., normal heart sounds, no neurological deficits, skin warm and dry]. Differential diagnosis includes vasovagal syncope, orthostatic hypotension, cardiac syncope, neurocardiogenic syncope, and seizures. Ordered [diagnostic tests e.g., ECG, complete blood count, basic metabolic panel, Holter monitor, tilt table test] to evaluate potential etiologies. Patient education provided regarding syncope management, including avoiding triggers, hydration, and recognizing warning signs. Follow-up recommended with [specialist e.g., cardiology, neurology] as needed. ICD-10 code: [appropriate ICD-10 code e.g., R55].