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
Syncope and collapse
Covers various types of syncope and collapse, including vasovagal and orthostatic.
Hypotension
Low blood pressure, a common cause of syncope and collapse.
Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified
Includes other related symptoms like dizziness and lightheadedness that may accompany syncope.
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?
When to use each related code
Description |
---|
Syncope |
Collapse |
Presyncope |
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).