Orthopnea
ICD-10 R06.01 is a billable code used to indicate a diagnosis of orthopnea.
Orthopnea is a condition characterized by difficulty breathing when lying flat, which is often relieved by sitting or standing. This symptom is commonly associated with heart failure, chronic obstructive pulmonary disease (COPD), and other respiratory or cardiac conditions. Patients may report an increase in shortness of breath when supine, leading to a need for multiple pillows or a reclined position during sleep. The underlying pathophysiology often involves fluid redistribution in the thoracic cavity when supine, exacerbating pulmonary congestion. Clinical evaluation may include a thorough history, physical examination, and diagnostic tests such as chest X-rays, echocardiograms, or pulmonary function tests to determine the underlying cause. Accurate documentation of orthopnea is crucial for appropriate management and coding, as it can significantly impact treatment decisions and patient outcomes.
Detailed history of present illness, including onset, duration, and triggers of orthopnea.
Patients with congestive heart failure presenting with worsening orthopnea.
Ensure to document any associated symptoms such as cough or wheezing.
Acute assessment of respiratory status, vital signs, and immediate interventions.
Patients presenting with acute exacerbation of COPD or heart failure.
Document the immediate treatment provided and response to interventions.
Used for follow-up visits for patients with chronic conditions like heart failure presenting with orthopnea.
Document the patient's history, examination findings, and treatment plan.
Internal medicine specialists should focus on chronic disease management.
Orthopnea specifically refers to difficulty breathing when lying flat, while dyspnea is a more general term for shortness of breath that can occur in various positions.
