ICD-10 Coding for Shortness of Breath on Exertion(R06.09, R06.02)
Complete ICD-10-CM coding and documentation guide for Shortness of Breath on Exertion. 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 on Exertion
R06.00-R06.09Primary Range
Abnormalities of breathing
This range includes codes for various types of dyspnea, including exertional dyspnea.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| R06.09 | Other forms of dyspnea | Use when dyspnea is specifically documented as occurring during exertion. |
|
| R06.02 | Shortness of breath | Use when dyspnea is not specified as exertional. |
|
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 on exertion
Essential facts and insights about Shortness of Breath on Exertion
Primary ICD-10-CM Codes for shortness of breath on exertion
Decision Criteria
clinical Criteria
- Dyspnea occurs specifically during exertion.
documentation Criteria
- Exertion level and context are documented.
Clinical Validation Requirements
- Patient reports dyspnea specifically occurring during exertion.
- Documented exertion level, such as walking or climbing stairs.
Code-Specific Risks
- Misuse when exertion is not specified, leading to incorrect coding.
Coding Notes
- Ensure documentation specifies exertion to use R06.09.
R06.02 - Shortness of breath
Use when dyspnea is not specified as exertional.
Applicable To
- General shortness of breath
Excludes
- Dyspnea on exertion (R06.09)
Clinical Validation Requirements
- Patient reports general shortness of breath without exertion specificity.
Coding Notes
Use for general dyspnea without exertion context.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Shortness of Breath on Exertion to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R06.09.
Impact
Clinical: Leads to inaccurate clinical assessments., Regulatory: May result in audit discrepancies., Financial: Potential for denied claims due to incorrect coding.
Mitigation Strategy
Train staff on the importance of documenting exertion context., Use templates that prompt for exertion details.
Impact
Reimbursement: Incorrect coding can lead to improper reimbursement., Compliance: May result in compliance issues during audits., Data Quality: Affects the accuracy of clinical data and reporting.
Mitigation Strategy
Use R06.09 when dyspnea is specified as occurring during exertion.
Impact
Lack of exertion context can lead to audit flags.
Mitigation Strategy
Implement documentation checks for exertion context.
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 on Exertion, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Shortness of Breath on Exertion
Use these documentation templates to ensure complete and accurate documentation for Shortness of Breath on Exertion. These templates include all required elements for proper coding and billing.
Exertional Dyspnea in Cardiology
Specialty: CardiologyRequired Elements
- Patient history of exertional dyspnea.
- Specific exertion level and context.
- Objective findings supporting dyspnea.
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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