ICD-10 Coding for Exertional Shortness of Breath(R06.02)
Complete ICD-10-CM coding and documentation guide for Exertional 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 Exertional Shortness of Breath
R06.00-R06.09Primary Range
Dyspnea and respiratory abnormalities
This range includes codes for various types of dyspnea, including exertional shortness of breath.
Key Information: ICD-10 code for exertional shortness of breath
Essential facts and insights about Exertional Shortness of Breath
Primary ICD-10-CM Code for exertional shortness of breath
Decision Criteria
clinical Criteria
- Patient experiences SOB after walking short distances or climbing stairs.
documentation Criteria
- Documented evidence of SOB during exertion without other primary conditions.
Applicable To
- Exertional shortness of breath
Excludes
- Dyspnea related to other conditions (e.g., pneumonia, heart failure)
Clinical Validation Requirements
- 6MWT distance <300m with desaturation ≥4%
- Patient reports SOB after minimal exertion
Code-Specific Risks
- Misuse as a primary code when an underlying condition is present
Coding Notes
- Ensure documentation clearly links SOB to exertion and excludes other primary conditions.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
COPD with (acute) exacerbation
J44.1Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Exertional 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: Misdiagnosis of the severity of dyspnea., Regulatory: Non-compliance with documentation standards., Financial: Potential denial of claims due to insufficient documentation.
Mitigation Strategy
Use standardized templates for documenting exertional SOB., Train staff on the importance of detailed documentation.
Impact
Reimbursement: Incorrect reimbursement due to improper code sequencing., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Ensure underlying conditions like COPD or CHF are coded as primary.
Impact
Exertional SOB coded as primary when an underlying condition is present.
Mitigation Strategy
Regular audits and training on code sequencing rules.
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 Exertional Shortness of Breath, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Exertional Shortness of Breath
Use these documentation templates to ensure complete and accurate documentation for Exertional Shortness of Breath. These templates include all required elements for proper coding and billing.
Exertional SOB in a patient with COPD
Specialty: PulmonologyRequired Elements
- Patient history of COPD
- 6MWT results
- Oxygen saturation levels
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Exertional Shortness of Breath? Ask your questions below.