Internal Medicine Coding Alert

Question: A 55-year-old established patient reports to my internist, saying 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 physician provides a level three E/M, diagnoses "episodic abnormality of consciousness; etiology uncertain," and requests a consult from a neurologist. Which ICD-9 codes apply to this condition?

Oregon 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 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity ...) with 780.02 appended.