ICD-10 Guide

R06.5

Mouth breathing

BILLABLE STATUSYes

IMPLEMENTATION DATEOctober 1, 2015

LAST UPDATED09/11/2025

Code Description

ICD-10 R06.5 is a billable code used to indicate a diagnosis of mouth breathing.

Key Diagnostic Point:

Mouth breathing is characterized by the inhalation and exhalation of air through the mouth rather than the nose. This condition can arise from various underlying issues, including nasal obstruction, allergies, or anatomical abnormalities such as a deviated septum. Chronic mouth breathing can lead to several complications, including dry mouth, dental issues, and altered facial growth patterns in children. It may also be associated with sleep disorders, such as obstructive sleep apnea. Clinically, mouth breathing can be identified through patient history and physical examination, where signs such as dry lips, dental caries, and altered oral flora may be observed. Laboratory findings may include allergy testing results or imaging studies that reveal structural abnormalities. The condition is often exacerbated by environmental factors, such as exposure to allergens or irritants, and can significantly impact quality of life, leading to fatigue and decreased concentration.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

Variety of underlying causes requiring thorough evaluation
Potential for co-existing conditions that complicate diagnosis
Need for detailed documentation to support the diagnosis
Variability in clinical presentation among different patient populations

Audit Risk Factors

Inadequate documentation of the underlying cause
Failure to link mouth breathing to specific clinical scenarios
Misclassification of mouth breathing as a primary diagnosis without supporting evidence
Lack of follow-up documentation for chronic cases

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Detailed patient history, including duration and frequency of mouth breathing, associated symptoms, and any previous treatments.

Common Clinical Scenarios

Patients presenting with chronic nasal congestion, allergies, or sleep disturbances.

Billing Considerations

Consideration of comorbidities such as asthma or chronic obstructive pulmonary disease (COPD) that may influence treatment.

Emergency Medicine

Documentation Requirements

Acute assessment of airway patency, vital signs, and immediate interventions if necessary.

Common Clinical Scenarios

Acute respiratory distress or allergic reactions leading to sudden onset of mouth breathing.

Billing Considerations

Rapid evaluation of potential life-threatening conditions such as anaphylaxis or severe asthma exacerbation.

Coding Guidelines

Inclusion Criteria

Use R06.5 When

Follow the official ICD
CM coding guidelines, ensuring that the diagnosis is supported by clinical documentation and that any underlying conditions are also coded appropriately

Exclusion Criteria

Do NOT use R06.5 When

No specific exclusions found.

Related CPT Codes

99213CPT Code

Established patient office visit, Level 3

Clinical Scenario

Used for follow-up visits regarding chronic mouth breathing and associated conditions.

Documentation Requirements

Document the patient's history, examination findings, and treatment plan.

Specialty Considerations

Internal medicine may focus on comorbidities, while ENT may focus on anatomical evaluations.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of symptoms like mouth breathing, improving the ability to capture the complexity of patient presentations and their underlying causes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of symptoms like mouth breathing, improving the ability to capture the complexity of patient presentations and their underlying causes.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of symptoms like mouth breathing, improving the ability to capture the complexity of patient presentations and their underlying causes.

Resources

Clinical References

•
ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

•
ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What are the common causes of mouth breathing?

Common causes include nasal obstruction due to allergies, infections, or anatomical issues such as a deviated septum. Other factors may include sleep disorders and chronic respiratory conditions.

ICD-10 R06.5 is a billable code used to indicate a diagnosis of mouth breathing.