Shortness Of Breath ICD 10 and ICD 11 coding is made simple with our tips and guidelines, written by expert Medical Coders. This article will teach you all about the coding and billing guidelines you will need to code shortness of breath and other related conditions.
How To Code Shortness Of Breath ICD 10 & 11
In the ICD 10 book, there is a separate chapter for coding of signs and symptoms named as the ‘Symptoms, signs, and abnormal findings, not elsewhere classified — R00-R99‘.
“R” codes in ICD 10 represent symptoms, signs of different diseases not elsewhere classified.
What Is Shortness Of Breath?
Shortness of breath, also known as “Dyspnea,” is defined as chest tightness or hunger for air. In other words, it is a feeling of suffocation in which one cannot breathe normally (when one can’t get enough air).
Shortness of breath is one of the symptoms of Acute or chronic respiratory disease as well as other disease conditions such as:
- Corona Virus disease 2019 (COVID 19)
- Chronic obstructive pulmonary disease (COPD)
- Congestive heart failure
- Pulmonary edema
- Lung Cancer
- Severe obesity
- Pulmonary fibrosis
- Infections and allergies
- Anxiety disorder
Shortness Of Breath ICD 10
Shortness Of Breath ICD 10 is coded as R06.02.
As mentioned earlier, Dyspnea is a symptom, and according to the ICD 10 coding guidelines, there are some conditions to code a symptom and not to code a symptom as well
There are some Exclusions for ICD 10 code R06.02. Type 1 Excludes for ICD 10 R06.02 are:
- Acute respiratory distress syndrome – J80
- Respiratory arrest – R0.2
- The respiratory arrest of newborn – P28.81
- Respiratory distress syndrome of newborn – P22
- Respiratory failure – J96
- Respiratory failure of newborn – P28.5
When Type 1 excludes is present, we will note code ICD 10 R06.02 because, as per ICD 10 guidelines, when a confirmed disease diagnosis is current, there is no need to code a symptom separately of the same disease.
Chest Pain With Shortness Of Breath ICD 10
ICD 10 codes for chest pain are divided according to its cause to more specification of patient’s condition. However, there is an ICD 10 code for unspecified chest pain. In case the cause is not documented.
ICD 10 for chest pain are:
- R07.0 Pain in throat
- R07.1 Chest pain on breathing
- R02 Precordial pain
- R07.81 Pleurodynia
- R07.82 Intercostal pain
- R07.89 Other chest pain
- R07.9 Chest pain unspecified
There is no combination code in ICD 10 to code Shortness Of Breath and chest pain together so we will code Dyspnea R06.02 with the code for chest pain according to its cause. For example, if Dyspnea and chest pain are mentioned in the patients’ documents, but if no cause of chest pain has been discussed, then R07.9 should be coded.
ICD 10 Code For Shortness Of Breath Unspecified
The ICD 10 Code For Shortness Of Breath Unspecified is R06.00.
Approximate synonyms for this code are:
- Shortness of breath
- Respiratory distress
- Paroxysmal nocturnal dyspnea
ICD 10 Code For Wheezing And Shortness Of Breath
The ICD 10 Code For Wheezing (Not otherwise specified) is R06.2.
Most of the time, shortness of breath with wheeze are the cardinal symptoms of Asthma, but this is not the only reason for wheezing with dyspnea.
According to the ICD 10 coding guidelines, ICD 10 of Asthma J45.- is type 1 excluded for ICD 10 wheezing R06.2. This means both ICD 10 codes can not be coded simultaneously.
So if wheezing is due to Asthma and confirmed diagnosis is mentioned, then Asthma J45.- should be coded. If wheezing is unspecified, R06.2 should be coded with ICD 10 for Dyspnea R06.02.
Shortness Of Breath In Pregnancy ICD 10
Shortness of breath is not a pathological condition in pregnancy, but some physiological changes can cause shortness of breath.
In 1st trimester, the reason for Shortness Of Breath is increased progesterone levels. In the 2nd and 3rd trimesters, the increased intra-abdominal pressure due to fetus growth and the increased size is reasons for shortness of breath.
ICD 10 code for Dyspnea in pregnancy is not specifically for dyspnea but for all pregnancy-related conditions throughout the pregnancy. So ICD 10 codes are following:
O26 Pregnancy-related conditions, unspecified (non-billable)
O26.90 Pregnancy-related conditions, unspecified trimester
O26.91 Pregnancy-related conditions, first trimester
O26.92 Pregnancy-related conditions, second trimester
O26.93 Pregnancy-related conditions, third trimester
Chronic Shortness Of Breath ICD 10
Chronic Shortness Of Breath ICD 10 is coded as R06.02.
Chronic dyspnea refers to the condition of breathlessness that lasts for more than 4-8 weeks and is mainly caused by:
Chronic obstructive pulmonary disorder (COPD) – J44.9
Asthma – J45.-
Congestive heart failure – I50.20
Myocardial infarction NOS – I21.9
Interstitial lung disease – J84.9
Pneumonia – J44.9
Psychogenic disorders – F54
There is no separate ICD 10 code for all chronic diseases with dyspnea or Chronic Dyspnea. However, according to Section I.B.4 of the ICD 10 CM guidelines, “Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider.”
This means that you will code the patient’s symptoms if the provider cannot establish a diagnosis.
So ICD 10 for Dyspnea R06.02 will be used if the confirmed diagnosis is not documented. If the confirmed diagnosis is recorded in the medical documentation, symptoms do not need to be coded.
Chronic Cough With Shortness Of Breath ICD 10
Chronic Cough With Shortness Of Breath ICD 10 is coded as R05.3.
This ICD 10 code is also applicable for Persistent cough, Refractory cough, and Unexplained cough.
Type 1 Exclusions are:
- Smoker’s cough – J41.0
- Whooping cough – A37
Exercise Induced Shortness Of Breath ICD 10
Exercise Induced Shortness Of Breath ICD 10 is coded as R06.09 (Dyspnea On Exertion).
History Of Shortness Of Breath ICD 10
History Of Shortness Of Breath ICD 10 is coded as Z87.09 (Personal history of other diseases of the respiratory system).
According to the ICD 10 guidelines, history codes should not be coded as a primary diagnosis with any service provided by a physician.
ICD 10 Code For Palpitations And Shortness Of Breath
ICD 10 Code For Palpitations And Shortness Of Breath is coded as a combined code.
ICD 10 code for Palpitations is R00.2, and the ICD 10 code for the Dyspnea is R06.02. Both codes, when coexisting, indicate heart disease, but if no confirm the diagnosis is present in the medical notes of a patient, then both ‘R’ codes should be reported.
ICD 10 Of Shortness Of Breath And Fatigue
The ICD 10 Of Shortness Of Breath And Fatigue is not specified. There is no combination for fatigue and shortness of breath. ICD 10 code for fatigue varies according to its type.
ICD 10 code for Chronic fatigue, unspecified, is R53.82. and for any other type, we code it as different fatigue ICD 10 code for additional fatigue is R53.83.
ICD 10 for Dyspnea R06.02 should be coded as primary and Unspecified, or other codes should not be set as primary diagnosis in pointer setting.
Shortness Of Breath ICD 11 Codes
The Shortness Of Breath ICD 11 Code is coded as Dyspnea MD11.5.
Type 1 exclusions:
- Transient tachypnea of newborn – KB23.1
How To Code Shortness Of Breath On Exertion ICD 10 & 11
Shortness of breath on exertion means difficulty breathing due to excessive physical work or exercising.
In typical cases, it means when someone feels running out of air while exercising or running, etc. Still, it can be caused due to different underlying diseases while doing simple tasks of physical exertion, i.e., walking, going up steps, etc.
Common causes of dyspnea are:
- Cardiovascular diseases, i.e., Angina, Ischemic heart diseases, congestive heart failure, etc.
- Respiratory disorders like Asthma, COPD, etc.
- Other conditions like Anemia etc.
ICD 10 Code For Shortness Of Breath On Exertion
The ICD 10 Code For Dyspnea On Exertion is R06.09 (dyspnea on exertion).
ICD 11 Code For Shortness Of Breath On Exertion
ICD 11 has vast codes for the symptoms according to underlying conditions than ICD 10.
While coding the simple dyspnea on exertion, not due to any disease, ICD 11 code MD11.5 should be used.
But if a confirmed diagnosis is mentioned along with dyspnea, then ICD 11 codes vary according to the specific disease.
For example, ICD 11 for cardiac dyspnea (cardiac asthmatic dyspnea) is BD11.Z.
Code also the related conditions and then add code severity as well.
Use Additional if desired:
ICD 11 for No limitation of physical activity (NYHA Class I) is XS3A
ICD 11 for Slight limitation of physical activity (NYHA Class II) is XS6B
ICD 11 for Marked limitation of physical activity (NYHA Class III) is XS9T
ICD 11 for Unable to carry on any physical activity without discomfort (NYHA Class IV) is XS9F
Similarly, additional codes for Acute or chronic conditions are also available, i.e., XT5R Acute XT8W Chronic
How To Code Cough With Shortness Of Breath ICD 10 & 11
Cough is the body’s natural response to clear the airway from irritants that cause infection of the respiratory tract. Common irritants are smoke, dust, mucus, etc. A cough can be acute, subacute, or chronic, depending upon its duration as well as its cause.
It lasts less than three weeks and is usually caused by a common cold or sinusitis.
Subacute cough lasts from three to eight weeks and remains after the initial cold, or respiratory infection is over.
The chronic cough usually persists for more than eight weeks. It is mainly caused by gastroesophageal reflux disease (GERD), chronic lung diseases such as Asthma, pulmonary fibrosis, chronic obstructive pulmonary disease (COPD), postnasal drip from sinus infections or allergies, and interstitial lung diseases.
Cough With Shortness Of Breath ICD 10
Cough With Shortness Of Breath ICD 10 is coded as R06.02 with the code for cough, according to its type, such as:
R05 Cough – Non-billable
R05.1 Acute cough
R05.2 Subacute cough
R05.3 Chronic cough
R05.4 Cough syncope
R05.6 Other specified coughs
R05.9 Cough, unspecified
R06.02 for shortness of breath with appropriate cough code according to its type.
Cough With Shortness Of Breath ICD 11
Cough with shortness of breath ICD 11 is coded as Cough MD12.
- Cough with hemorrhage MD22
How To Code Shortness Of Breath With Hypoxia ICD 10 & 11
Hypoxia is a condition in which oxygen supply to the body tissues is insufficient than usual, leading to inadequate oxygen supply to blood cells known as hypoxemia. It can be caused by multiple factors; chronic dyspnea can also lead to hypoxic respiratory failure.
Shortness Of Breath With Hypoxia ICD 10
Shortness Of Breath With Hypoxia ICD 10 is coded as Hypoxia R09.02 with Dyspnea R06.02.
- Hypoxemia (low blood oxygen)
- Hypoxia (low oxygen levels)
Shortness Of Breath With Hypoxia ICD 11 Codes
Shortness Of Breath With Hypoxia ICD 11 is coded as Hypoxia MD11.1 or Hypoxic Respiratory Arrest MD33.
How to Code Shortness Of Breath Newborn ICD 10 & 11
Breathing difficulty is common after birth, during the first few hours of a baby’s life. It happens due to the transition of the baby from a fluid environment to air, so, commonly, a baby may suffer from shortness of birth soon after delivery as the lungs of a baby become functional after the first breath.
However, the more complex problems that a newborn baby may experience are:
- Meconium aspiration
- Respiratory distress syndrome
- Transient tachypnea
- Congenital lungs malformations
Shortness Of Breath Newborn ICD 10
Shortness of breath newborn ICD 10 is coded as P22.0.
Different causes include:
P22.0 for respiratory distress syndrome of the newborn
P22.1 for transient tachypnea of the newborn (TTN)
P22.8 for other respiratory distress of newborn
P22.9 for respiratory distress of newborn, unspecified
As per ICD 10 guidelines, these codes should be used on the newborn record, not on the mother’s record.
Type 1 Exclude:
- The respiratory arrest of newborn P28.81
- Respiratory failure of newborn P28.5
Shortness Of Breath Newborn ICD 11
The Shortness of breath newborn ICD 11 is coded as Newborn Dyspnea KB23.Y.
Other specified respiratory distress of newborn
ICD 11 code for the Transient tachypnea of the newborn is KB23.1
ICD 11 code for the Respiratory distress syndrome of newborn, unspecified is KB23.0Z
By Sana Akhtar
Expert Medical Coding & Billing