ICD-10 Coding for Breathing Problems(R06.02, J45.901)
Complete ICD-10-CM coding and documentation guide for Breathing Problems. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Breathing Problems
R06-R09Primary Range
Symptoms and signs involving the circulatory and respiratory systems
This range includes codes for various respiratory symptoms, including shortness of breath and other breathing abnormalities.
Chronic lower respiratory diseases
This range covers chronic respiratory conditions like asthma and COPD, which often present with breathing problems.
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 and no other cause is identified. |
|
| J45.901 | Unspecified asthma with (acute) exacerbation | Use when asthma exacerbation is documented without specific severity classification. |
|
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 shortness of breath
Essential facts and insights about Breathing Problems
Primary ICD-10-CM Codes for breathing problem
Decision Criteria
clinical Criteria
- Patient presents with unexplained shortness of breath.
documentation Criteria
- No other respiratory or cardiac conditions are documented.
Applicable To
- Dyspnea
Excludes
- Acute respiratory distress syndrome (J80)
Clinical Validation Requirements
- Patient reports difficulty breathing
- No definitive cause identified
Code-Specific Risks
- Risk of using as a catch-all without proper documentation
Coding Notes
- Ensure documentation specifies the absence of other conditions causing the symptom.
J45.901 - Unspecified asthma with (acute) exacerbation
Use when asthma exacerbation is documented without specific severity classification.
Applicable To
- Asthma exacerbation
Excludes
- Chronic obstructive pulmonary disease with acute exacerbation (J44.1)
Clinical Validation Requirements
- Documented asthma history
- Evidence of exacerbation such as increased use of rescue inhalers
Coding Notes
Ensure asthma exacerbation is clearly 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 Breathing Problems 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 incomplete patient history., Regulatory: Non-compliance with CMS guidelines., Financial: Potential for denied claims.
Mitigation Strategy
Always ask about tobacco use during patient history intake., Include tobacco use status in the medical record.
Impact
Reimbursement: May lead to reduced reimbursement due to lack of specificity., Compliance: Increases risk of audit failures., Data Quality: Decreases accuracy of patient records.
Mitigation Strategy
Ensure documentation includes specific details like severity and exacerbation status.
Impact
Inaccurate coding of respiratory failure without supporting ABG results.
Mitigation Strategy
Ensure ABG results are documented and support the diagnosis of respiratory failure.
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 Breathing Problems, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Breathing Problems
Use these documentation templates to ensure complete and accurate documentation for Breathing Problems. These templates include all required elements for proper coding and billing.
Acute Respiratory Distress
Specialty: PulmonologyRequired Elements
- Chief complaint
- History of present illness
- Physical exam findings
- Diagnostic test results
- Assessment and plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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