Internal Medicine Coding Alert

If your internist notes in a chart today that a patient's presenting complaint is "shortness of breath," you select diagnosis 786.05 (Shortness of breath). You'll still have a single choice when ICD-10 goes into effect in October 2013, with R06.02. Making the switch will be simple because code R06.02 retains the same descriptor as 786.05: shortness of breath.

ICD-10 difference: Because the descriptor remains the same, the conversion to ICD-10 will offer no difference in reporting shortness of breath. Generally, however, the new classification system (ICD-10) aims to provide significant improvements through greater detailed information and the ability to expand in order to capture additional advancements in clinical medicine.

Coding tips: Shortness of breath is usually a symptom of an underlying disorder such as asthma (493.90, Asthma unspecified), pneumonia (486, Pneumonia organism unspecified), or cardiac ischemia (414.9, Chronic ischemic heart disease unspecified). Shortness of breath is generally caused by disorders of the cardiac or respiratory system, but other systems (such as the musculoskeletal, endocrine, hematologic, or psychiatric) may be the cause. Physicians should perform a comprehensive history and comprehensive physical exam on the patient to help guide diagnosis and treatment.