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code the syncope that caused the fall as secondary Error 6: Overuse of Unspecified Codes When Specific Codes Exist Wrong: Patient with documented medication-induced orthostatic hypotension Coded as R55 only Right: Same patient I95.2 (principal) + T code for medication + R55 (secondary) How to avoid: Always look for documented causes before accepting symptom-only coding Medicare and Commercial Payer Requirements for Syncope Different payers have different expectations for syncope workup and documentation

Yu IS, Pereira AAL, Lee M, Korphaisarn K, Marshall J, Segelov E, O'Callaghan C, Lim HJ, Kopetz S , Loree JM

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Repeat injections require documented improvement from prior injections, and sessions beyond four require a clinical appeal with the MAC