Guest post: Coding and documentation challenges related to syncope

by Alba Kuqi, MD, CICA, CCS, CDIP, CCDS, CRCR, CSMC

Codes for symptoms, signs, and ill-defined conditions from Chapter 18 of the ICD-10-CM coding manual cannot be used as principal diagnosis or reasons for outpatient encounters when related diagnosis has been established, they may be assigned as an additional diagnosis. Examples include I44.2 and R55, Syncope due to a third-degree atrioventricular block.

1. When no related condition is defined and the symptom is the reason for the encounter, a code from Chapter 18 is assigned as the principal diagnosis even though other unrelated diagnoses may be listed.
2. Other situations in which codes from Chapter 18 can be appropriately used as the principal diagnosis for an inpatient admission include the following: 
   
   1. Presenting signs and symptoms are transient, and no definitive diagnosis can be made. 
   2. The patient is referred elsewhere for further study or treatment before a diagnosis is made. 
   3. A more precise diagnosis cannot be made for any other reason. 
   4. The symptom is treated in an outpatient setting without the additional workup required to arrive at a more definitive diagnosis. 
   5. A provisional diagnosis of a sign or symptom is made for a patient who fails to return for further investigation of care
   6. A residual late effect is a reason for admission, and the Alphabetic Index directs the coding professional to an alternative sequencing.

Reviewing for the underlying cause of syncope is important because the underlying cause would be sequenced as a principal diagnosis. CDI professionals should look for frequent secondary diagnoses that may affect severity of illness (SOI)/risk of mortality (ROM) such as CVA, encephalopathy, heart failure, hyponatremia, pneumonia, syndrome of inappropriate antidiuretic hormone secretion, and subdural hemorrhage.

Review for alternative principal diagnosis/underlying cause of syncope such as: 

• The adverse effect of drugs/medication
• Anemia
• Cardiac arrhythmias
• Cardiac vascular stenosis
• Congestive heart failure (CHF)
• Dehydration
• Diabetic nephropathy
• Electrolyte imbalance
• Hypoglycemia
• Hypotension
• Intoxication (alcohol)
• Neurologic conditions (Parkinson’s disease, stroke, tumors)
• Poisoning
• Transient ischemic attacks (TIA)
• Seizure disorders
• Sick sinus syndrome
• Urinary tract infections (UTI)

Also remember to pay attention to the Excludes 1 note which means “not coded here.” The code excluded should not be used at the same time as the code above the Excludes 1 note. The two conditions cannot be coded together, except when the two conditions are unrelated to each other. 

Syncope Exclude 1 notes include: 

• Cardiogenic shock
• Carotid sinus
• Heat syncope
• Neurocirculatory asthenia
• Neurogenic orthostatic hypotension
• Orthostatic hypotension
• Postprocedural shock
• Psychogenic syncope
• Shock not otherwise specified
• Shock complicating or following abortion or ectopic or molar pregnancy
• Shock complicating or following labor and delivery
• Stock-Adams attack
• Unconsciousness not otherwise specified

Editor’s note: Kuqi is the CDI supervisor at Prime Healthcare in Philadelphia. Click here to read the first part of this series. Contact her at albakuqi88@gmail.com. Opinions expressed are those of the author and do not necessarily reflect those of ACDIS, HCPro, or any of its subsidiaries.