By: Loretta Lathon, CPC, CRC, CDEO
A patient has Sick Sinus Syndrome and a permanent pacemaker. How do I code the patient’s condition correctly?
According to the National Institute of Health sick sinus syndrome is a group of heart rhythm issues in which the sino-atrial (SA) node, the heart’s natural pacemaker, does not function correctly. Sick sinus syndrome often manifests with little to no symptoms. In some cases, when symptoms arise, they may come and go. These symptoms can include heart palpitations, fatigue, shortness of breath, fainting, chest pains and confusion.
The American Hospital Association (AHA) Coding Clinic, notes that although sick sinus syndrome may be controlled with a permanent pacemaker, the condition itself is still considered to be present and reportable as a chronic condition. It would be appropriate to assign code I49.5 for sick sinus syndrome and Z95.0 for the presence of a cardiac pacemaker when both are documented and supported in the medical record. Documentation should clearly indicate the presence of both and the impact on patient care to utilize these codes.
