Syncope and collapse
ICD-10 R55 is a billable code used to indicate a diagnosis of syncope and collapse.
Syncope, commonly referred to as fainting, is a transient loss of consciousness due to a temporary reduction in blood flow to the brain. It is characterized by a sudden onset, a brief duration, and spontaneous recovery. Collapse refers to a sudden fall or loss of posture, which may or may not be associated with loss of consciousness. The clinical presentation can vary widely, with patients experiencing symptoms such as dizziness, lightheadedness, palpitations, or visual disturbances prior to the event. Common causes of syncope include vasovagal responses, orthostatic hypotension, cardiac arrhythmias, and neurological conditions. Diagnostic evaluation often includes a thorough history and physical examination, orthostatic vital signs, electrocardiogram (ECG), and possibly further cardiac or neurological testing. It is essential to differentiate syncope from other causes of transient loss of consciousness, such as seizures or metabolic disturbances, to ensure appropriate management and coding.
Detailed history of the event, including triggers, duration, and recovery; physical examination findings; and results of any diagnostic tests.
Patients presenting with recurrent syncope, particularly in the context of underlying cardiovascular disease or autonomic dysfunction.
Consideration of comorbid conditions that may contribute to syncope, such as diabetes or hypertension.
Immediate assessment findings, including vital signs, ECG results, and any interventions performed.
Acute presentations of syncope in patients with potential life-threatening conditions such as arrhythmias or significant blood loss.
Rapid assessment and documentation are critical, as timely intervention may be necessary.
When an ECG is performed to evaluate the cause of syncope.
Document the indication for the ECG and any findings.
In cardiology, ensure that the ECG findings are linked to the diagnosis.
R55 should be used when a patient experiences syncope or collapse that is not classified elsewhere, and the documentation supports this diagnosis.
