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v1.0.0
ICD-10 Guide
ICD-10 CodesR09.02

R09.02

Hypoxemia

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/11/2025

Code Description

ICD-10 R09.02 is a billable code used to indicate a diagnosis of hypoxemia.

Key Diagnostic Point:

Hypoxemia refers to an abnormally low level of oxygen in the blood, specifically in the arterial blood. It is a critical condition that can lead to significant morbidity and mortality if not promptly addressed. Symptoms may include shortness of breath, rapid breathing, confusion, cyanosis (bluish discoloration of the skin), and increased heart rate. Hypoxemia can result from various underlying conditions such as chronic obstructive pulmonary disease (COPD), pneumonia, pulmonary embolism, and heart failure. Laboratory findings often include arterial blood gas analysis showing low partial pressure of oxygen (PaO2) and potentially elevated carbon dioxide levels (PaCO2). The clinical context is essential for diagnosis, as hypoxemia can be acute or chronic, and its management may vary based on the underlying cause. Prompt identification and treatment are crucial to prevent complications such as organ dysfunction and respiratory failure.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of underlying causes requiring thorough clinical evaluation
  • Need for precise documentation of oxygen saturation levels
  • Differentiation from other respiratory conditions
  • Potential for acute versus chronic classification

Audit Risk Factors

  • Inadequate documentation of oxygen saturation levels
  • Failure to specify the underlying cause of hypoxemia
  • Misclassification of acute versus chronic hypoxemia
  • Lack of supporting lab results in the medical record

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Detailed history and physical examination, including vital signs and oxygen saturation levels.

Common Clinical Scenarios

Patients presenting with chronic respiratory conditions, acute exacerbations, or post-operative complications.

Billing Considerations

Ensure documentation reflects the severity and duration of hypoxemia, as well as any comorbid conditions.

Emergency Medicine

Documentation Requirements

Acute care documentation must include immediate assessment findings, oxygen saturation, and interventions performed.

Common Clinical Scenarios

Patients with acute respiratory distress, trauma, or suspected pulmonary embolism.

Billing Considerations

Rapid assessment and documentation of the patient's response to treatment are critical for accurate coding.

Coding Guidelines

Inclusion Criteria

Use R09.02 When
  • Follow official ICD
  • CM guidelines for coding symptoms and abnormal findings
  • Ensure that the code is supported by clinical documentation and lab results

Exclusion Criteria

Do NOT use R09.02 When
No specific exclusions found.

Related CPT Codes

94640CPT Code

Pressurized inhalation treatment

Clinical Scenario

Used in conjunction with hypoxemia management in patients requiring bronchodilation.

Documentation Requirements

Document the indication for treatment and response to therapy.

Specialty Considerations

Ensure that the procedure is linked to the diagnosis of hypoxemia.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of hypoxemia, improving the ability to capture the severity and underlying causes of the condition.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of hypoxemia, improving the ability to capture the severity and underlying causes of the condition.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of hypoxemia, improving the ability to capture the severity and underlying causes of the condition.

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 is the difference between hypoxemia and hypoxia?

Hypoxemia specifically refers to low oxygen levels in the blood, while hypoxia refers to low oxygen levels in tissues. Hypoxemia can lead to hypoxia, but they are not synonymous.