ICD-10 Coding for Dyspnea on Exertion(R06.02, I50.21)
Complete ICD-10-CM coding and documentation guide for Dyspnea on Exertion. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Dyspnea on Exertion
R06-R06.9Primary Range
Abnormalities of breathing
This range includes codes for various breathing abnormalities, including dyspnea on exertion.
Heart failure
Heart failure can cause dyspnea on exertion, and these codes are used when heart failure is the primary diagnosis.
Chronic obstructive pulmonary disease
COPD can cause dyspnea on exertion, and these codes are used when COPD is the primary diagnosis.
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 on exertion is the primary symptom without a known underlying cause. |
|
| I50.21 | Acute systolic (congestive) heart failure | Use when dyspnea on exertion is due to acute systolic heart failure. |
|
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 on exertion
Essential facts and insights about Dyspnea on Exertion
Primary ICD-10-CM Codes for dyspnea on exertion
Decision Criteria
clinical Criteria
- Patient experiences dyspnea specifically during exertion.
coding Criteria
- No primary condition like heart failure or COPD is identified.
Applicable To
- Dyspnea on exertion
Excludes
- Dyspnea due to known conditions like heart failure or COPD
Clinical Validation Requirements
- Patient reports dyspnea specifically related to exertion
- Exclusion of other primary causes through diagnostic tests
Code-Specific Risks
- Misuse when an underlying condition is present
- Incorrect sequencing with primary conditions
Coding Notes
- Ensure documentation specifies exertion as the trigger for dyspnea.
I50.21 - Acute systolic (congestive) heart failure
Use when dyspnea on exertion is due to acute systolic heart failure.
Applicable To
- Heart failure with reduced ejection fraction
Excludes
- Heart failure due to hypertension
Clinical Validation Requirements
- Echocardiogram showing reduced ejection fraction
- Elevated BNP levels
Coding Notes
Ensure heart failure is documented as the primary cause of dyspnea.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Other abnormalities of breathing
R06.89Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Dyspnea on Exertion to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R06.02.
Impact
Clinical: Misrepresentation of patient condition., Regulatory: Potential audit issues., Financial: Incorrect reimbursement due to coding errors.
Mitigation Strategy
Educate clinicians on documentation requirements., Use templates that prompt for exertion details.
Impact
Reimbursement: Incorrect coding may lead to reduced reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Code the underlying condition (e.g., J18.9 for pneumonia) as primary.
Impact
Using R06.02 as primary when an underlying condition is present.
Mitigation Strategy
Educate coding staff on proper code sequencing.
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 on Exertion, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Dyspnea on Exertion
Use these documentation templates to ensure complete and accurate documentation for Dyspnea on Exertion. These templates include all required elements for proper coding and billing.
Dyspnea on exertion with no clear underlying cause
Specialty: General MedicineRequired Elements
- Patient history
- Exertion details
- Diagnostic tests
- Exclusion of other conditions
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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