ICD-10 Coding for Shortness of Breath(R06.02)
Complete ICD-10-CM coding and documentation guide for Shortness of Breath. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Shortness of Breath
R06.0-R06.9Primary Range
Abnormalities of breathing
This range includes codes for various types of breathing abnormalities, including shortness of breath.
Key Information: ICD-10 code for shortness of breath
Essential facts and insights about Shortness of Breath
Primary ICD-10-CM Code for shortness of breath
Decision Criteria
clinical Criteria
- Patient reports difficulty breathing without exertion and normal diagnostic tests.
coding Criteria
- No other respiratory or cardiac conditions are identified.
Applicable To
- Dyspnea NOS
Clinical Validation Requirements
- Subjective report of difficulty breathing
- Normal chest X-ray and EKG if no underlying condition is identified
Code-Specific Risks
- Using as a catch-all without proper documentation of exclusion of other conditions.
Coding Notes
- Ensure documentation specifies the absence of other conditions that could explain the shortness of breath.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Orthopnea
R06.01Differential 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 Shortness of Breath 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 inappropriate treatment., Regulatory: Non-compliance with documentation standards., Financial: Potential for denied claims.
Mitigation Strategy
Always assess and document potential underlying causes., Use specific language to describe SOB.
Impact
Reimbursement: Incorrect coding can lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Code J45.901 for asthma exacerbation instead.
Impact
Failure to document specific details can lead to audit issues.
Mitigation Strategy
Ensure thorough documentation of all clinical findings related to SOB.
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 Shortness of Breath, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Shortness of Breath
Use these documentation templates to ensure complete and accurate documentation for Shortness of Breath. These templates include all required elements for proper coding and billing.
Emergency Department Visit for SOB
Specialty: Emergency MedicineRequired Elements
- Onset and duration of SOB
- Associated symptoms
- Response to interventions
- Differential diagnosis considered
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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