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R55
ICD-10-CM
Syncope and Collapse

Find comprehensive information on syncope and collapse diagnosis, including clinical documentation tips, ICD-10 codes (R55), medical coding guidelines, differential diagnosis, and treatment considerations. This resource helps healthcare professionals accurately document and code syncope and collapse episodes, covering vasovagal syncope, orthostatic hypotension, cardiac syncope, and neurocardiogenic syncope. Learn about evaluating syncope, diagnostic workup, and best practices for patient care related to syncope and collapse.

Also known as

Fainting
Blackout
Temporary Loss of Consciousness

Diagnosis Snapshot

Key Facts
  • Definition : Temporary loss of consciousness with spontaneous recovery, usually from insufficient blood flow to the brain.
  • Clinical Signs : Sudden onset, brief duration, lightheadedness, nausea, sweating, pale skin, weak pulse.
  • Common Settings : Emergency room, primary care clinic, cardiology, neurology.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC R55 Coding
R55

Syncope and collapse

Covers various types of syncope and collapse, including vasovagal and orthostatic.

I95

Hypotension

Low blood pressure, a common cause of syncope and collapse.

R00-R99

Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified

Includes other related symptoms like dizziness and lightheadedness that may accompany syncope.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is syncope due to a clearly documented underlying cause?

  • Yes

    Is it due to orthostatic hypotension?

  • No

    Is it a carotid sinus syncope?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Syncope
Collapse
Presyncope

Documentation Best Practices

Documentation Checklist
  • Syncope vs collapse differentiation
  • Onset, duration, frequency documented
  • Precipitating factors, prodrome, recovery
  • Associated symptoms (pallor, diaphoresis)
  • ECG, orthostatic vitals, neuro exam

Mitigation Tips

Best Practices
  • Document pre-syncopal symptoms for accurate ICD-10 coding (R55)
  • Thorough HPI improves CDI for syncope vs. collapse diagnosis
  • Order EKG, orthostatics to meet CMS compliance for syncope
  • Neuro exam crucial for compliant billing and risk mitigation
  • Evaluate for cardiac causes, document for accurate E/M coding

Clinical Decision Support

Checklist
  • Verify Loss of Consciousness: documented, duration noted
  • Orthostatic vitals: recorded, positive or negative
  • ECG performed: rhythm documented, findings described
  • Neuro exam: performed, deficits or focal findings noted
  • Consider high-risk features: cardiac hx, exertional onset

Reimbursement and Quality Metrics

Impact Summary
  • Syncope and Collapse: Coding accuracy impacts reimbursement for observation vs. inpatient admission.
  • Accurate E/M coding for Syncope maximizes revenue, avoids denials. Focus on documentation specificity.
  • Timely diagnosis coding of Syncope improves hospital reporting quality metrics for patient safety indicators.
  • Proper Syncope documentation impacts severity scores, affecting case mix index and hospital reimbursement.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes for . Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • Document syncope triggers
  • Specify if witnessed/ unwitnessed
  • Code underlying cause, e.g., arrhythmia
  • R55 for syncope, unspecified
  • Consider pre-syncope symptoms

Documentation Templates

Patient presented with a chief complaint of syncope or collapse.  Onset of the syncopal episode was (sudden, gradual), occurring (time, date, situation: e.g., upon standing, during exertion, after a meal).  Pre-syncopal symptoms, if present, included (dizziness, lightheadedness, nausea, palpitations, sweating, blurred vision, tinnitus, pallor, chest pain, shortness of breath).  Duration of unconsciousness was approximately (duration), with (spontaneous, assisted) recovery.  Post-syncopal symptoms included (confusion, disorientation, fatigue, headache, muscle aches).  Patient denies (or reports) any history of similar episodes, seizures, cardiac disease, arrhythmias, orthostatic hypotension, or medication use (list specific medications if applicable).  Physical examination revealed (normal or abnormal findings related to vital signs, cardiovascular exam, neurological exam).  Differential diagnosis includes vasovagal syncope, orthostatic hypotension, cardiac arrhythmia, seizure, neurocardiogenic syncope, situational syncope, carotid sinus hypersensitivity.  Initial diagnostic workup may include (ECG, blood glucose, complete blood count, electrolyte panel, cardiac enzymes).  Further evaluation may be warranted based on initial findings, including (tilt table test, Holter monitor, echocardiogram, electroencephalogram, neurological consultation, cardiology consultation).  Patient education provided regarding syncope management, including (avoiding triggers, hydration, recognizing warning signs).  Treatment plan includes (addressing underlying cause if identified, lifestyle modifications, medication management if indicated, referral to specialist as needed).  Follow-up scheduled for (date, time).