ICD-10 Coding for Dyspnea(R06.02, R06.03)
Complete ICD-10-CM coding and documentation guide for Dyspnea. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Dyspnea
R06.0-R06.9Primary Range
Abnormalities of breathing
This range includes codes for various types of dyspnea and related respiratory symptoms.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R06.02 | Shortness of breath | Use when dyspnea is documented without further specification. |
|
| R06.03 | Acute respiratory distress | Use when acute respiratory distress is documented with supporting clinical evidence. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for dyspnea
Essential facts and insights about Dyspnea
Primary ICD-10-CM Codes for dyspnea
Decision Criteria
documentation Criteria
- Document specific activity and severity level for dyspnea.
Applicable To
- Dyspnea NOS
Excludes
- Respiratory distress syndrome (J80)
Clinical Validation Requirements
- Patient reports dyspnea with specific activity
- O2 saturation <94% on room air
Code-Specific Risks
- Risk of under-documentation if severity and context are not specified.
Coding Notes
- Ensure documentation specifies the activity level and severity of dyspnea.
R06.03 - Acute respiratory distress
Use when acute respiratory distress is documented with supporting clinical evidence.
Applicable To
- ARDS
Excludes
- Chronic respiratory failure (J96.1-)
Clinical Validation Requirements
- ABG with PaO2/FiO2 ≤300
- Bilateral infiltrates on CXR
Coding Notes
Document all clinical findings supporting ARDS diagnosis.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Dyspnea to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R06.02.
Impact
Clinical: May lead to inadequate treatment planning., Regulatory: Non-compliance with documentation standards., Financial: Potential for denied claims due to insufficient detail.
Mitigation Strategy
Train staff on detailed documentation practices., Use templates to guide comprehensive documentation.
Impact
Reimbursement: Potential for lower reimbursement due to unspecified coding., Compliance: Non-compliance with coding guidelines., Data Quality: Decreased accuracy in clinical data.
Mitigation Strategy
Use the most specific code available based on documentation.
Impact
Risk of audits due to frequent use of unspecified codes.
Mitigation Strategy
Encourage specific documentation and use of detailed codes.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Dyspnea, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Dyspnea
Use these documentation templates to ensure complete and accurate documentation for Dyspnea. These templates include all required elements for proper coding and billing.
Emergency Department Visit for Dyspnea
Specialty: Emergency MedicineRequired Elements
- Onset and duration of dyspnea
- Severity scale (0-10)
- Associated symptoms
- Objective findings (RR, SpO2)
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Dyspnea? Ask your questions below.