ICD-10 Coding for Trouble Breathing(R06.02, J96.90)
Complete ICD-10-CM coding and documentation guide for Trouble Breathing. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Trouble Breathing
R06.0-R06.9Primary Range
Abnormalities of breathing
This range includes codes for various types of breathing difficulties, including shortness of breath and unspecified dyspnea.
Respiratory failure, not elsewhere classified
This range includes codes for respiratory failure, which may be related to severe cases of trouble breathing.
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 shortness of breath is the primary symptom without a more specific underlying condition. |
|
| J96.90 | Respiratory failure, unspecified, without hypoxia or hypercapnia | Use when respiratory failure is documented but specific type (hypoxic or hypercapnic) is not specified. |
|
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 trouble breathing
Essential facts and insights about Trouble Breathing
Primary ICD-10-CM Codes for trouble breathing
Decision Criteria
clinical Criteria
- Presence of shortness of breath as a primary symptom without a specific diagnosis.
documentation Criteria
- Detailed description of dyspnea onset and severity.
Applicable To
- Dyspnea on exertion
Clinical Validation Requirements
- Patient reports new-onset shortness of breath at rest unrelieved by inhaler
- SpO2 < 94% on room air
Code-Specific Risks
- Risk of under-documenting associated conditions leading to incorrect coding.
Coding Notes
- Ensure documentation specifies the nature and onset of dyspnea.
J96.90 - Respiratory failure, unspecified, without hypoxia or hypercapnia
Use when respiratory failure is documented but specific type (hypoxic or hypercapnic) is not specified.
Excludes
- Acute respiratory distress syndrome (J80)
Clinical Validation Requirements
- ABG with pH <7.35 or PaCO2 >45 mmHg
- Documentation of BiPAP/intubation
Coding Notes
Ensure ABG results and respiratory support are documented.
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 Trouble Breathing to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R06.02.
Impact
Clinical: Leads to misdiagnosis or inappropriate treatment., Regulatory: Non-compliance with documentation standards., Financial: Potential for claim denials or reduced reimbursement.
Mitigation Strategy
Use specific terms and measurements., Include detailed history and physical exam findings.
Impact
Reimbursement: Incorrect coding can lead to reduced reimbursement., Compliance: May result in non-compliance with coding guidelines., Data Quality: Affects the accuracy of clinical data.
Mitigation Strategy
Use J45.901 (acute asthma exacerbation) + R06.02 only if dyspnea persists after exacerbation management.
Impact
Risk of coding respiratory failure without supporting documentation.
Mitigation Strategy
Ensure ABG results and respiratory support are documented.
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 Trouble Breathing, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Trouble Breathing
Use these documentation templates to ensure complete and accurate documentation for Trouble Breathing. These templates include all required elements for proper coding and billing.
Emergency Department Note for Dyspnea
Specialty: Emergency MedicineRequired Elements
- History of present illness
- Associated symptoms
- Physical exam findings
- Diagnostic studies
- Impression and plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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