Internal Medicine Coding Alert

Question: A 55-year-old new patient reports to the internist for his initial visit. He says that for the past three weeks, he has "zoned out" for no reason several times, but did not lose consciousness during any of the episodes. The internist provides a level-two E/M and diagnoses "episodic abnormality of consciousness; etiology uncertain." Which ICD-9 codes apply to this condition?

Indiana Subscriber

Answer: According to ICD-9, use 780.02 (Alteration of consciousness; transient alteration of awareness) when a patient experiences "temporary, recurring spells of reduced consciousness." Given your description, this is the best diagnosis for the patient.

On the claim, report 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; straightforward medical decision-making) with 780.02 appended.

Exception: You noted that the patient did not "black out" during any of the episodes. If the patient actually lost consciousness during these altered states, report 99202 with 780.09 (Alteration of consciousness; other).