Syncope is one of the more difficult symptoms to link to a cause due to the variety of precipitating factors. Some of the verbiage you may see as an admitting diagnosis are:
- Syncope (of unknown cause)
- Vasovagal response of unknown etiology
- Near syncope due to medication
- Pre-syncope possibly due to either stress or dehydration
- Drop attack
Syncope is a sudden, complete but brief loss of consciousness (LOC) due to insufficient cerebral blood flow or insufficient cerebral oxygen and/or glucose, with postural collapse followed by spontaneous, complete recovery.
Near syncope can be defined as lightheadedness and a sense of an impending faint without LOC.
Pre-syncope can be defined as lightheadedness with muscle weakness, dizziness, and blurred vision.
The varying system sources and conditions that may cause syncope are orthostatic hypotension, metabolic derangement, cardiogenic, cerebrovascular, neuro-cardiogenic, neurological, or hematological.
Early documentation might not reveal the cause of the syncopal episode due to the elusive nature of the symptom; however, if the patient is appropriately admitted to inpatient status, the history, physical examination findings, testing and/or evaluation results, and the orders will likely provide some clues, or clinical indicators, as to the provider’s thought processes.
Orthostatic hypotension is the most common cause of syncope, but unless there are comorbidities, or initial blood work and evaluation show abnormal findings, orthostatic hypotension is usually treated in the clinic, emergency department, or while in observation status. If the above is present, and the patient is admitted as an inpatient, look for electrolyte abnormalities and provider orders such as TED stockings, adjustment of medications associated with hypotension, and increased fluid consumption.
Next to orthostatic hypotension, a common cause of syncope is cardiac arrhythmia. This may be difficult to diagnose without prolonged cardiac event monitoring, though there may be clues on the cardiac monitor. 1st degree and 2nd degree Mobitz I heart blocks usually have no symptoms and don’t necessarily cause syncope although they may be indicators of transient higher degree heart blocks, especially if any type of bundle branch block is also present. Antiarrhythmic drugs or a pacemaker might be ordered for cardiac arrhythmia syncope, or an order for echocardiography for suspected heart structure abnormalities.
Continuing down the cardiac line of possibilities, there might be orders for a chest/abdominal CT for suspected dissection, ruptured aneurysm, or a pulmonary embolism, with the latter also possibly having an order for a V/Q scan. The provider may perform cardiac sinus massage to rule in/out carotid sinus syncope. If a stress test is performed or ordered to be done as an outpatient, the provider may be suspecting cardiac syncope, or a stress test may also be ordered for a patient with known risk factors for coronary disease. A beta blocker or known history of valve repair might be a consideration for cardiac mechanical syncope.
Stenosis of vertebrobasilar (VB) or bilateral carotid arteries has been known to cause syncope. Stenosis of VB arteries caused by atherosclerosis can result in vertebrobasilar insufficiency (VBI), with testing ranging from a Dix-Hallpike maneuver to a CT, MRI, MRA, and/or angiogram. Look for a finding of a bruit with further studies such as an ultrasound, CT, MRI, or a carotid angiogram if carotid artery stenosis is suspected.
Vasovagal, or neurocardiogenic syncope can be the result of a disturbance in the autonomic nervous system termed autonomic dysfunction. An order for a head-up tilt table test may be ordered to confirm autonomic dysfunction as a cause for syncope.
If there has been a history of a head trauma, with or without neurological symptoms, a CT head may be ordered. An EEG may be ordered to rule in/out a seizure.
Blood loss anemia (acute or chronic) frequently causes anemia, although chronic anemia is well tolerated until it becomes severe. Depending on the cause of the anemia, the findings and comorbidities, the workup could be completed on an outpatient basis after treatment for the anemia.
Using clinical indicators to validate documented diagnoses and conditions, confirm medical necessity, and/or assist in formulating a query to clarify a more appropriate diagnosis than a symptom not only helps the CDS, but also assists the provider in documenting a complete, precise encounter which will aid the coder after the hospital visit, and ultimately benefit the patient.
Karen Newhouser, RN, BSN, CCM, CCDS, CCS, CDIP
Director of Education, MedPartners
Optum360. 2016. Guide to clinical validation, documentation and coding: Validating code assignments with clinical documentation. 2017. Optum360 LLC.
Pinson, R.D. & Tang, C.L. 2016. CDI Pocket Guide. 2017. HCPro.