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Question: I have a report that states the pulmonologist performed pulmonary stress testing and diagnosed the patient with dyspnea. What is dyspnea and how do I report the testing and diagnosis?

Missouri Subscriber

Answer: Dyspnea is term that physicians use to describe shortness of breath. Typically, shortness of breath is a symptom of heart and lung problems, such as asthma, pneumonia, chronic obstructive pulmonary disease (COPD), or allergies. Patients who have a history of smoking, a respiratory infection, or are overweight (body mass index [BMI] of over 30) may also experience dyspnea.

The ICD-10-CM code set includes a code category specific for dyspnea diagnoses. Under the R06.0 (Dyspnea) category, you’ll find five codes that specify different conditions:

• R06.00 (Dyspnea, unspecified)
• R06.01 (Orthopnea)
• R06.02 (Shortness of breath)
• R06.03 (Acute respiratory distress)
• R06.09 (Other forms of dyspnea)

You’ll assign R06.02 for the dyspnea diagnosis listed in the report.

Pulmonologists can order several tests to evaluate the patient for dyspnea, including pulmonary stress testing. During the stress test the provider measures how much oxygen the patient takes in and the amount of carbon dioxide exhaled.

Assign 94618 (Pulmonary stress testing (eg, 6-minute walk test), including measurement of heart rate, oximetry, and oxygen titration, when performed) to report the stress test during the encounter.

Mike Shaughnessy, BA, CPC, Production Editor, AAPC