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v1.0.0
ICD-10 Guide
ICD-10 CodesR68.2

R68.2

Dry mouth, unspecified

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

Code Description

ICD-10 R68.2 is a billable code used to indicate a diagnosis of dry mouth, unspecified.

Key Diagnostic Point:

Dry mouth, or xerostomia, is a condition characterized by a decrease in saliva production, leading to a dry sensation in the mouth. This symptom can arise from various underlying causes, including medications, systemic diseases, dehydration, and radiation therapy. Patients may experience difficulty swallowing, altered taste, and increased dental caries due to the lack of saliva, which plays a crucial role in oral health. The condition can be acute or chronic, and its severity can significantly impact a patient's quality of life. Diagnosis typically involves a thorough clinical history, assessment of medication use, and evaluation of systemic conditions. Laboratory tests may be conducted to assess salivary flow rates or to rule out underlying conditions. It is essential to identify the etiology of dry mouth to provide appropriate management and treatment options.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of potential underlying causes
  • Need for thorough patient history and medication review
  • Differentiation from other oral conditions
  • Potential for co-existing conditions

Audit Risk Factors

  • Inadequate documentation of underlying causes
  • Failure to specify acute vs. chronic presentation
  • Misidentification of the primary diagnosis
  • Lack of supporting clinical findings

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Comprehensive patient history, including medication review and systemic disease assessment.

Common Clinical Scenarios

Patients presenting with dry mouth due to medication side effects or systemic diseases such as diabetes.

Billing Considerations

Consideration of comorbidities that may contribute to xerostomia.

Emergency Medicine

Documentation Requirements

Acute assessment of dry mouth in the context of dehydration or acute illness.

Common Clinical Scenarios

Patients presenting with dry mouth due to acute illness, dehydration, or medication administration.

Billing Considerations

Rapid assessment and documentation of hydration status and potential interventions.

Coding Guidelines

Inclusion Criteria

Use R68.2 When
  • Follow official ICD
  • 10 coding guidelines, ensuring accurate documentation of the patient's condition and any underlying causes
  • Use R68
  • 2 when the cause of dry mouth is not specified

Exclusion Criteria

Do NOT use R68.2 When
No specific exclusions found.

Related CPT Codes

99213CPT Code

Established patient office visit, Level 3

Clinical Scenario

Used when evaluating a patient with dry mouth in an outpatient setting.

Documentation Requirements

Document history, examination findings, and medical decision-making.

Specialty Considerations

Internal medicine may require more detailed documentation of comorbidities.

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 dry mouth, improving the ability to capture the complexity of patient presentations and underlying causes.

ICD-9 vs ICD-10

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

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of symptoms like dry mouth, improving the ability to capture the complexity of patient presentations and 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 should I document to support the use of R68.2?

Document the patient's history, any medications that may contribute to dry mouth, and any relevant clinical findings. Include the duration and severity of symptoms to provide a comprehensive picture.