Error 3: Missing the Underlying Cardiac Cause Wrong: Patient with syncope and documented arrhythmia Coded as R55 (principal), I48.91 (secondary) Right: When causation is documented Code I48.91 (principal), R55 (secondary) How to avoid: Always query when a potential causative condition is present Error 4: Failing to Code Orthostatic Hypotension Wrong: Documentation states "orthostatic hypotension" Only R55 coded Right: Documentation states "orthostatic hypotension" Code I95.1 (principal), R55 (secondary) How to avoid: Read the entire medical record, not just the problem list Error 5: Incorrect Sequencing with Injuries Wrong: Patient syncopizes and breaks wrist R55 coded as principal diagnosis Right: Same scenario S52.501A (wrist fracture) principal, R55 secondary, W19.XXXA (fall) external cause How to avoid: Remember that injuries requiring treatment are typically the principal diagnosis
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Kumar SK, Rajkumar V, Kyle RA, van Duin M, Sonneveld P, Mateos M-V, et al
