Pulmonology Coding Alert

Consider: An underlying disorder could be causing this symptom.

When a physician notes a patient's presenting complaint as "shortness of breath," you would report the diagnosis as 786.05 (Shortness of breath).

Come 2013 when ICD-9 transitions to ICD-10, the code will become R code R06.02, keeping the same descriptor -- "shortness of breath" -- word for word.

ICD difference: The conversion to ICD-10 will offer no difference. 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.

Coder tips: Shortness of breath is usually a symptom of an underlying disorder, for instance, asthma (493.90, Asthma unspecified), pneumonia (486, Pneumonia organism unspecified), and cardiac ischemia (414.9, Chronic ischemic heart disease unspecified). While shortness of breath is generally caused by disorders of the cardiac or respiratory system, other system such as musculoskeletal, endocrine, hematologic, and psychiatric may be the cause.

In view of this, it would be medically necessary for the physician to perform a comprehensive history to address this issue, as well as a comprehensive physical exam on a patient in order to help guide the diagnosis and treatment.