Shortness of breath
ICD-10 R06.02 is a billable code used to indicate a diagnosis of shortness of breath.
Shortness of breath, or dyspnea, is a common symptom that can indicate a variety of underlying health issues. It is characterized by an uncomfortable awareness of breathing, which may be accompanied by a feeling of suffocation or difficulty in breathing. Dyspnea can be acute or chronic and may arise from respiratory, cardiovascular, or systemic conditions. Common causes include asthma, chronic obstructive pulmonary disease (COPD), pneumonia, heart failure, and anxiety disorders. The symptom can manifest during exertion or at rest and may vary in intensity. Clinicians often assess dyspnea using various scales, such as the Modified Medical Research Council (mMRC) dyspnea scale, to evaluate its severity and impact on daily activities. Diagnostic approaches typically involve a thorough history and physical examination, pulmonary function tests, imaging studies like chest X-rays or CT scans, and laboratory tests to identify underlying causes. Accurate coding of R06.02 requires careful documentation of the symptom's context, duration, and associated findings to ensure appropriate clinical management and reimbursement.
Documentation should include a detailed history of the symptom, associated conditions, and any relevant diagnostic tests performed.
Patients presenting with chronic respiratory conditions, heart failure, or unexplained dyspnea.
Consideration of comorbidities and their impact on the patient's respiratory status is crucial for accurate coding.
Acute care documentation must include the onset, duration, and severity of dyspnea, as well as any immediate interventions provided.
Patients presenting with acute shortness of breath due to asthma exacerbation, pulmonary embolism, or acute heart failure.
Rapid assessment and documentation of vital signs and oxygen saturation levels are essential in emergency settings.
Used when assessing lung function in patients presenting with shortness of breath.
Documentation must include the reason for the spirometry and the results.
Pulmonologists may require additional tests based on the patient's history.
Documentation should include the patient's history of shortness of breath, associated symptoms, any relevant diagnostic tests, and the clinical context in which the symptom occurs.
