Internal Medicine Coding Alert

Question: Our internist saw a patient and documented the reason for the visit as "Episodes of abnormality of consciousness of uncertain etiology." Which ICD-9 codes apply to this condition?

Indiana Subscriber

Answer: You should report 780.02 (Transient alteration of awareness) for this diagnosis. According to the ICD-9 manual, this code includes "temporary, recurring spells of reduced consciousness," which sounds as if it fits what your patient experienced during her visit with the internist.

If the patient stated that she actually went unconscious during the episode, you should instead report 780.09 (Alteration of consciousness; other).

Answers to You Be the Coder and Reader Questions were reviewed by Kathy Pride, CPC, CCS-P, director of consulting and training for QuadraMed in Reston, Va.; and Bruce Rappoport, MD, CPC, a board-certified internist who works with physicians on compliance, documentation, coding and quality issues for Rachlin, Cohen & Holtz LLP, a Fort Lauderdale, Fla.-based accounting firm with healthcare expertise.