What Are The Dermatology Billing Practice Trends To Watch?

What Are The Dermatology Billing Practice Trends To Watch?

The healthcare industry is in a continual state of flux, driven by shifts in scientific advancements, patient privacy and insurance providers’ policies. This has also impacted medical coding and billing, with rules changing periodically and new codes being introduced every now and then. To stay ahead of the curve, physician practices and providers of medical billing services in USA must stay up to date with the current trends. Adapting to changes with the help of a reliable medical billing and coding service will ensure efficient claims submission for timely and accurate reimbursement.

Though all areas of healthcare face denials and audits, these concerns are more common in dermatology. Dermatology billing and coding requires thorough reporting, detailed information on procedures completed, and must follow multiple procedure rules, which can lead to billing and coding errors. Staying abreast with latest trends – such as changing codes, billing rules, documentation requirements and payment methods is crucial for success with dermatology medical billing.

Let’s check out the 3 top dermatology billing trends that medical practices need to pay attention to:

  • COVID-19 Related Skin Conditions: A wide spectrum of skin conditions has been reported in association with coronavirus. At the American Academy of Dermatology annual meeting held virtually in April 2021, the most discussed topics were COVID-19’s effect on the skin and coverage for vitiligo and atopic dermatitis treatments. A poster presented at AAD VMX 2021 highlighted skin issues due to mask-wearing such as acne, erythema and rhytides. Dermatologists need to ensure that these conditions are reported using the correct ICD-10 codes:
    • L80 – Vitiligo
    • L20 – Atopic dermatitis
    • L70 – Acne
      • L70.9 – Acne, unspecified
    • L52 – Erythema nodosum
    • L53 – Other erythematous conditions
      • L53.8 – Other specified erythematous conditions
      • L53.9 – Erythematous condition, unspecified
    • L54 – Erythema in diseases classified elsewhere
    • L98.8 – Other specified disorders of the skin and subcutaneous tissue ( Rhytide of forehead, Rhytide of glabellar skin, Rhytides and wrinkles, forehead, and Rhytides and wrinkles, glabellar)

Dermatologists have an important role in the management of infectious diseases outbreaks like COVID-19. In the coming year and beyond, they should stay focused on their important role in such health care crises and consider how they can best diagnose and effectively treat new skin manifestations while ensuring the highest quality for all patients who need dermatologic care.

  • Telehealth Dermatology Appointments gain popularity: Before the pandemic, telemedicine use in dermatology was minimal. In June 2020, the National Psoriasis Foundation’s COVID-19 Task Force provided a new list of recommendations for patients and practitioners on telehealth usage. According to the study, candidates for telehealth are clinically stable patients on treatment, those requiring follow-up care or prescription refills and those with COVID-19 who are experiencing flares. It was also recommended that new patient telehealth consultations should be restricted to only those facing significant barriers to in-person care. In-person visits should also be provided for patients experiencing disease progression.

    Patients are also upbeat about remote office visits. An Updox survey found that:

    • 65 percent of the patients who used telehealth services liked the convenience
    • 63 percent appreciated not being exposed to other sick patients
    • 44 percent favored the ease of scheduling appointments
    • 38 percent noted the simplicity of scheduling follow-up appointments

These statistics provide evidence of telehealth technology’s versatility and accessibility. According to a study presented at the annual AAD conference, nearly 67% of people plan to utilize teledermatology appointment options post-pandemic – even after clinics allow in-person visits. Going forward, videos, photos, and patient-reported data are likely to be the basis telehealth in dermatology settings. Dermatologists also need to know the rules for coding and billing telehealth visits.

Outsourced Medical Billing: Outsourcing your dermatology medical billing services to a reliable partner can help your practice in many ways. Dermatology practices are under added pressure to cut overhead costs in these challenging times. They also have to deal with coding and billing changes that happen from time to time and maintain compliance with standards. Outsourcing is a great option to gain time to focus on the changing demands in dermatology care. Partnering with a reliable provider of dermatology medical billing services can help practices streamline operations, cut costs, and ensure proper coding and billing to secure optimal payment for services rendered.

Though dermatologists provide many types of medical, surgical and cosmetic procedures and services, getting reimbursed appropriately can be a challenge. In Medscape’s 2019dermatologist compensation survey, respondents cited getting fair reimbursement and following multiple rules and regulations as the most challenging part of their job. Compared with 38% of all physicians, 46% of dermatologists reported spending 10-19 hours a week on paperwork and administrative tasks. These findings suggest that partnering with a professional dermatology medical billing and coding company is the best option for practices to translate patient services into error-free claims, get appropriate reimbursement, and improve their bottomline.

How To Document And Code Cardiogenic Shock

How To Document And Code Cardiogenic Shock

Regarded as a life-threatening condition, cardiogenic shock occurs when the heart is suddenly unable to supply enough blood to the vital organs of the body. This results in reduced blood pressure levels and failure of organs. Reports from the National Heart, Lung, and Blood Institute (NHLBI) show that heart attack is the most common cause of cardiogenic shock. A severe attack can damage the heart’s main pumping chamber (left ventricle). Even though cardiogenic shock is rare, it’s often deadly and fatal, if not treated immediately. Billing and coding for cardiology conditions can be complex. For correct clinical documentation of this disorder, physicians can rely on the services of reputable medical billing companies.

As mentioned above, heart attack is the main cause of cardiogenic shock. Other related causes include – inflammation of the heart muscle (myocarditis), weakened heart (from any cause), sudden blockage of a blood vessel in the lung (pulmonary embolism), fluid buildup around the heart, damage/rupture of the heart valve and infection of the heart valves (endocarditis). Drug overdoses or poisoning with substances can also lead to cardiogenic shock.

Signs and Symptoms

Cardiogenic shock is more common in males than in females, particularly elder males. The symptoms may depend on how quickly the blood pressure drops and how low it gets. Some individuals may experience mild symptoms at first, whereas others may have no symptoms and then immediately lose consciousness. Common signs and symptoms include –

  • Swollen feet
  • Sweating and cold extremities, like fingers and toes
  • Slow heart rate
  • Rapid breathing
  • Pressure, fullness or a squeezing pain in the center of the chest that lasts for more than a few minutes
  • Pale, blue hue to the skin
  • Nausea and vomiting
  • Loss of consciousness
  • Confusion and anxiety
  • Bulging veins in the neck
  • A sudden drop in blood pressure

Identifying the above signs or symptoms early can help reduce the risk of developing cardiogenic shock. There are several risk factors associated with the condition – previous history of heart attack or failure, people with blockages (coronary artery disease), people with history of high diabetes or blood pressure, people with long-term valvular disease and plaque buildup in the coronary arteries (arteries supplying blood to the heart).

Treating the Symptoms of Cardiogenic Shock Early

Diagnosis of cardiogenic shock will begin with a complete physical examination wherein the level of pulse and blood pressure are checked. Additional tests include – Electrocardiogram (ECG or EKG), Echocardiogram, Cardiac catheterization (angiogram) and Chest X-ray. As per reports from the Journal of the American Heart Association, physicians need to perform the EKG (reveal irregularities in the heart rhythm) within 10 minutes of the person presenting. Treatment modalities for the condition may depend on the results of the diagnosis tests.

As cardiogenic shock is a severe medical emergency, treatment modalities for the condition need to be initiated immediately. Treatment modalities aim to restore blood flow to the brain and other organs as quickly as possible to protect them from damage. Treatment modalities may include a combination of medications, heart procedures or other surgeries, depending on the person’s condition. These include – intravenous fluids, mechanical ventilation, mechanical circulatory support (MCS) devices, and heart catheterization for coronary angiography.

Applicable Medical Codes

Cardiology medical billing and coding involves using the relevant ICD-10 and CPT codes on the medical claims submitted to health insurers. A professional medical coding company provides the services of skilled medical coders who are up to date with the changing coding regulations and guidelines for the cardiology specialty.

Diagnosis Codes

  • R57 Shock, not elsewhere classified
  • R57.0 Cardiogenic shock
  • R57.1 Hypovolemic shock
  • R57.8 Other shock
  • R57.9 Shock, unspecified

CPT Codes

  • 33990 Insertion of ventricular assist device, percutaneous including radiological supervision and interpretation; left heart arterial access only
  • 33991 Insertion of ventricular assist device, percutaneous including radiological supervision and interpretation; left heart, both arterial and venous access, with transseptal puncture
  • 33992 Removal of percutaneous left heart ventricular assist device, arterial or arterial and venous cannula(s), at separate and distinct session from insertion
  • 33993 Repositioning of percutaneous right or left heart ventricular assist device with imaging guidance at separate and distinct session from insertion
  • 33995 Insertion of ventricular assist device, percutaneous, including radiological supervision and interpretation; right heart, venous access only
  • 33997 Removal of percutaneous right heart ventricular assist device, venous cannula, at separate and distinct session from insertion

ICD-10 Procedure Codes

  • 5A0221D Assistance with Cardiac Output using Impeller pump, Continuous
  • 5A02216 Assistance with Cardiac Output using Other Pump, Continuous

Even though there are no guaranteed screening tests for cardiogenic shock, identifying the root causes of symptoms is key to preventing this condition. Patients experiencing the signs of a heart attack need to seek emergency medical care immediately. In addition, incorporating several lifestyle – and more heart healthy measures like – maintaining healthy blood pressure and cholesterol levels, managing stress levels, getting regular physical exercise, maintaining a moderate body weight, and stopping the habit of smoking and alcohol consumption can reduce the risk of heart disease in the long run.

Medical billing and coding for cardiology disorders can be challenging. To ensure maximum accuracy and efficiency in medical billing and coding tasks, healthcare practices can utilize medical billing services in USA from reputable billing and coding companies.

Diagnostic Coding Guidelines For Myocardial Infarction

Diagnostic Coding Guidelines For Myocardial Infarction

Regarded as a life-threatening condition, myocardial infarction (MI) or acute myocardial infarction (AMI) occurs due to sudden blockage of blood flow to the heart, causing tissue damage. According to the National Heart, Lung, and Blood Institute, if an area of the heart muscle goes too long without blood flow and is not immediately restored, that area starts to die. Without adequate blood flow, the heart muscles get deprived of essential nutrients and oxygen that are needed to function properly. Also called heart attack, acute coronary syndrome, coronary thrombosis, the condition is usually the result of a blockage in one or more of the coronary arteries. In most cases, a blockage can develop due to a buildup of plaque, a substance mostly made of fat, cholesterol, and cellular waste products. A minor tear in the plaque triggers blood platelets and other substances to form a clot that blocks the flow of blood to the heart. Irreversible damage begins within 30 minutes of blockage. If left untreated, the condition can be fatal causing severe complications like – abnormal heart rhythms (arrhythmias), heart failure and even sudden cardiac arrest. Treatment modalities for this have improved dramatically over the years. Billing and coding for these types of severe cardiology conditions can be complex. By utilizing medical billing services in USA from a reliable provider, healthcare practices can ensure correct and timely medical billing and claims submission.

Reports from the Centers for Disease Control and Prevention (CDC) suggest that heart disease is the leading cause of death in the United States. A myocardial infarction occurs about every 40 seconds in the country. Ever year, about 805,000 Americans experience a heart attack. Of these, 605,000 people have a first heart attack, and 200,000 people have already had a heart attack. It is estimated that about 1 in 5 heart attacks are silent, meaning the damage is done, but the person is not aware of it.

A spasm of a coronary artery that shuts down blood flow to part of the heart muscle is another cause of a heart attack. Aging, obesity, usage of tobacco and illicit drugs, a family history of heart attacks and other lifestyle diseases can increase the risk of this condition. In addition, infection with COVID-19 also may damage the heart in ways that result in a heart attack.

What Are The Symptoms Of Myocardial Infarction (MI)?

Chest pain and heart attack are the classic symptoms of myocardial infarction. The symptoms can vary from person to person and depend on the severity of the condition. It is important to note that not all people who have heart attacks experience the same symptoms or the same severity of symptoms. In fact, women are slightly more likely than men to report unusual symptoms. Some of the common symptoms of a heart attack include –

  • Pressure or tightness in the chest
  • Sweating
  • Shortness of breath
  • Pain in the chest, back, jaw, and other areas of the upper body (that lasts more than a few minutes or that goes away and comes back)
  • Nausea and vomiting
  • Dizziness
  • A fast heart rate

ICD- 10 Codes For Diagnosing And Coding AMI

Initial diagnosis of myocardial infarction (MI) involves a physical examination where in the cardiologists will check for irregularities in the heartbeat. The level of blood pressure, pulse and temperature will be checked. Patients will be connected to a heart monitor and tests like – electrocardiogram (EKG to measure heart’s electrical activity) and blood tests will be performed to check whether they are having the symptoms of a heart attack. Other additional diagnostic tests like – stress test, echocardiogram, chest X-ray, coronary catheterization (angiogram) and cardiac CT or MRI may also be performed as part of the diagnosis. Treatment options for MI include a combination of medications and surgical procedures. Surgical and other procedures include – coronary angioplasty and stenting and coronary artery bypass surgery. Certain healthcare practices offers cardiac rehabilitation programs that generally focus on four main areas — medications, lifestyle changes, emotional issues and a gradual return to a patients normal level of activities.

Types of AMI

Generally, there are different types of myocardial infarctions with several underlying causes. Identifying and diagnosing the specific type of MI as early as possible will help in determining the most appropriate treatment options. The different types of MI include –

  • Type 1 (spontaneous MI related to ischemia)
  • Type 2 (MI secondary to an ischemic imbalance)
  • Type 3 (MI resulting in death due to unavailable biomarker values)
  • Type 4a (MI associated with percutaneous coronary intervention [PCI])
  • Type 4b (MI associated with in-stent thrombosis)
  • Type 4c (MI associated with restenosis of coronary artery after previous percutaneous coronary intervention [PCI])
  • Type 5 (MI associated with coronary artery bypass graft [CABG])

ICD-10 – CM-Coding

In ICD-10, there are quite a few coding guidelines pertaining to the circulatory system and acute myocardial infarctions that we need to know in order to code for it accurately. However, having a basic knowledge of the condition – including the different terms used to describe it, as well as the causes, symptoms, and diagnosis is an important aspect. In ICD-10-CM, codes for acute myocardial infarction are located in Chapter 9 -Diseases of the Circulatory System (I00-I99) under Ischemic Heart Diseases (I20-I25). The documentation should provide the site (wall) of the AMI, arteries affected, whether it is initial or subsequent, and the type of AMI.

Acute MI – An acute MI is a myocardial infarction specified as acute or with a stated duration of 4 weeks (28 days) or less from onset. Acute MI codes from category I21 include –

  • I21 Acute myocardial infarction
  • I21.0 ST elevation (STEMI) myocardial infarction of anterior wall

    • I21.01 ST elevation (STEMI) myocardial infarction involving left main coronary artery
    • I21.02 ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery
    • I21.09 ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall
  • I21.1 ST elevation (STEMI) myocardial infarction of inferior wall

    • I21.11 ST elevation (STEMI) myocardial infarction involving right coronary artery
    • I21.19 ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall
  • I21.2 ST elevation (STEMI) myocardial infarction of other sites

    • I21.21 ST elevation (STEMI) myocardial infarction involving left circumflex coronary artery
    • I21.29 ST elevation (STEMI) myocardial infarction involving other sites
  • I21.3 ST elevation (STEMI) myocardial infarction of unspecified site
  • I21.4 Non-ST elevation (NSTEMI) myocardial infarction
  • I21.9 Acute myocardial infarction, unspecified
  • I21.A Other type of myocardial infarction

    • I21.A1 Myocardial infarction type 2
    • I21.A9 Other myocardial infarction type

Understanding The Difference Between STEMI and NSTEMI

Regarded as the most serious type of MI, an ST elevation myocardial infarction (STEMI) is caused by a sudden and long-term blockage of blood supply. Also called a Q-wave or transmural myocardial infarction, in this condition a large area of the heart muscle is damaged due to the blockage and an elevation of the ST segment on the electrocardiogram (ECG) occurs. On the other hand, a Non-ST elevation myocardial infarction (NSTEMI) is caused by a partial or temporary blockage. Also referred to as a non-Q wave or non-transmural MI, in this condition, the extent of the damage to the heart muscle may be relatively small based on the blood supplied by the affected artery.

Subsequent MI – This is an acute myocardial infarction occurring within 4 weeks (28 days) of a previous acute myocardial infarction, regardless of site. Subsequent MI codes from category I22 include –

  • I22 Subsequent ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction
  • I22.0 Subsequent ST elevation (STEMI) myocardial infarction of anterior wall
  • I22.1 Subsequent ST elevation (STEMI) myocardial infarction of inferior wall
  • I22.2 Subsequent non-ST elevation (NSTEMI) myocardial infarction
  • I22.8 Subsequent ST elevation (STEMI) myocardial infarction of other sites
  • I22.9 Subsequent ST elevation (STEMI) myocardial infarction of unspecified site

Use Additional Codes

The “Use additional” note provided at category I21 and category I22 indicates the following should be coded, if applicable –

  • Exposure to environmental tobacco smoke (Z77.22)
  • History of tobacco dependence (Z87.891)
  • Occupational exposure to environmental tobacco smoke (Z57.31)
  • Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility (Z92.82)
  • Tobacco dependence (F17.-)
  • Tobacco use (Z72.0)
  • Presence of hypertension (I10-I16)

The ICD-10-CM codes for myocardial infarction (MI) identify the site of the AMI, arteries affected, whether AMI temporal parameter is (initial or subsequent), and whether the MI is an ST elevation or non-ST elevation infarction. With accurate and comprehensive documentation, medical coders can determine the correct codes and the appropriate sequencing of ICD-10 codes to ensure efficient medical billing and coding. To ensure maximum accuracy and efficiency in medical billing and coding tasks, healthcare practices can depend on the services of a reputable cardiology medical billing company.

ICD-10 Codes to Report Adrenal Cancer

ICD-10 Codes to Report Adrenal Cancer

Adrenal cancer is a rare type of cancer that develops in the adrenal glands that are part of the endocrine system. Also called adrenocortical cancer, it occurs when abnormal cells form in or travels to the adrenal glands and creates changes or mutations in the DNA of an adrenal gland cell. Adrenal cancer can occur at any age. However, the condition tends to affect children younger than 5 years and adults aged 40-50 years. Most growths that form in the adrenal glands are non-cancerous (benign). If left untreated, it tends to spread to other areas beyond the adrenal glands and the chances for cure become low. On the other hand, if detected at an early stage, the patient has higher chances to be cured. Administering effective treatment modalities can help delay progression or recurrence of the condition. Billing and coding for this rare type of cancer can be challenging. Endocrinologists, surgical oncologists or other specialists who treat patients with adrenal cancer need to correctly understand the usage of medical codes. Relying on the services of reputable medical billing outsourcing companies with ample expertise in this field can ensure billing and coding efficiency.

Types of Adrenal Gland Tumors

There are two main types of adrenal cortex tumors – Adenomas (benign or non-cancerous tumors) and Carcinomas (malignant or cancerous tumors).

  • Benign Adenomas– Relatively small in size – usually less than 2 inches in diameter, these adenomas generally occur in only one adrenal gland. However, in certain rare cases, they can appear in both glands. People with this condition experience no specific symptoms.
  • Adrenal Cortical Carcinomas – Compared to benign adenomas, these are larger in size (more than 2 inches in diameter). These tumors can grow large enough to press on the organs causing more specific symptoms. In certain cases, these can produce certain key hormonal changes in the body.

Generally, most types of cancers found in the adrenal gland do not begin there and hence are not adrenal cancers. Instead, they tend to begin in other organs or tissues and then spread (metastasize) through the bloodstream to the adrenal glands.

Identifying the Signs and Symptoms of Adrenal Cancer

In most cases, the signs and symptoms of adrenal cancers are caused by the excess production of hormones like – androgen, estrogen, cortisol and aldosterone. It is easier to spot these signs and symptoms in children than in adults (as physical changes become more visible during puberty). Reports suggest that in about half of people with adrenal cancer, symptoms don’t appear until the tumor is large enough to press on other organs. Women with tumors (that cause increases in androgen) may have facial hair growth or deepening of the voice. Men with tumors (that cause increases in estrogen) may experience breast enlargement or breast tenderness. Some of the common symptoms of adrenal cancers include –

  • Weight gain
  • Pink or purple stretch marks on the skin
  • Nausea and vomiting
  • Muscle cramps or weakness
  • Loss of weight without trying
  • Loss of appetite
  • Hormone changes in women that might cause excess facial hair, hair loss on the head and irregular periods
  • Hormone changes in men that might cause enlarged breast tissue and shrinking testicles
  • High blood pressure/sugar
  • Frequent urination
  • Fever
  • Back pain
  • Abdominal bloating

Diagnosing and Treating Adrenal Cancer

Adrenal cancer diagnosis begins with a previous medical history evaluation and a complete physical examination. Physicians may perform blood and urine tests to identify the unusual levels of hormones (including cortisol, aldosterone and androgens) produced by adrenal glands.

Several imaging tests – Ultrasound, CT scan, MRI scan, Positron Emission Tomography (PET) scan and Adrenal Angiography – may be requested by physicians. These imaging tests help better locate any specific growths in the adrenal glands and to distinguish whether the tumor has spread to other parts of the body- including the lungs or liver. If the physicians suspect that the adrenal gland is cancerous, they may recommend performing an image-guided fine needle biopsy. This involves removing the affected adrenal gland or a part of it for a detailed analysis in the laboratory. This can help confirm whether a person has cancer and if so, exactly what types of cells are involved.

Common treatment modalities include – surgery, chemotherapy, radiation therapy and medications. The basic goal of surgery or adrenalectomy is to remove the entire adrenal cancer – right from its roots.

On the other hand, if the tumor has spread to the nearby organ structures – like the liver or kidneys – parts or all of those organs may be removed during the surgery. Radiation therapy or chemotherapy may be performed after adrenal cancer surgery to kill cancerous cells that may remain. Medications like Mitotane (Lysodren) may be recommended after surgery to reduce the risk of cancer recurrence. In addition, it can block excessive hormone production and may help reduce the size of the tumor.

ICD-10 Codes to Report Adrenal Cancer

Billing and coding for adrenal cancer can be complex as there are several rules related to reporting the condition accurately. Physicians must report the diagnostic tests and other treatment procedures performed using the right medical codes. Medical coding services can ensure the right use of relevant codes to bill for the procedures correctly.ICD-10 diagnosis codes for adrenal cancer include –

  • C74 Malignant neoplasm of adrenal gland
    • C74.0 Malignant neoplasm of cortex of adrenal gland
      • C74.00 Malignant neoplasm of cortex of unspecified adrenal gland
      • C74.01 Malignant neoplasm of cortex of right adrenal gland
      • C74.02 Malignant neoplasm of cortex of left adrenal gland
    • C74.1 Malignant neoplasm of medulla of adrenal gland
      • C74.10 Malignant neoplasm of medulla of unspecified adrenal gland
      • C74.11 Malignant neoplasm of medulla of right adrenal gland
      • C74.12 Malignant neoplasm of medulla of left adrenal gland
    • C74.9 Malignant neoplasm of unspecified part of adrenal gland
      • C74.90 Malignant neoplasm of unspecified part of unspecified adrenal gland
      • C74.91 Malignant neoplasm of unspecified part of right adrenal gland
      • C74.92 Malignant neoplasm of unspecified part of left adrenal gland

Relieving symptoms remains an important part of medical care and treatment, if an adrenal cancer is detected. This may involve symptom management, palliative care, or supportive care. However, care for people diagnosed with adrenal tumors doesn’t end when active treatment has finished. It is important to regularly check whether the tumor has reappeared, manage any related side-effects and monitor overall health. A regular follow-up appointment with the physician is important if a person had suffered adrenal tumors in the past. This may include regular physical examinations, medical tests, or both.

As the cancer can reappear at any time, it is important to stay in close contact with the medical team. Patients must discuss their symptoms – including any new symptoms or change in symptoms that may occur at regular intervals – with their physicians.

Medical billing and coding for adrenal cancer can be complex. By utilizing medical billing services in USA from a reliable provider, healthcare practices can ensure correct and timely medical billing and claims submission.

Have you treated adrenal cancer before? If so, how was your experience aiding the patient with this illness? Was there a lot of paperwork that went along with this patient’s situation?

Jargon Buster –

Benign Adenomas – These are non-cancerous, small size tumors that generally occur in only one adrenal gland.
Adrenalectomy (Adrenal Gland Removal) – Surgery to remove one or both adrenal glands.

What Is Dyspnea? Know your ICD-10 Codes to Bill

What Is Dyspnea? Know your ICD-10 Codes to Bill

Dyspnea refers to shortness of breath. It is a common symptom for many health issues reported in general practice and in hospital emergency rooms and can be a sign of a life-threatening condition. According to NCBI research, 7% of patients in hospital emergency rooms and 60% of those in ambulatory pulmonological practices complain of dyspnea. Practices providing treatments need to report the condition in medical records using correct medical codes, for which they can take the support of an experienced physician billing company.

While acute dyspnea could be due to conditions such as asthma, anxiety, pneumonia, any block in breathing passageways, allergy, anemia, heart failure, hypotension or low blood pressure, pulmonary embolism, collapsed lung, hiatal hernia or terminal illness, chronic dyspnea can be caused by asthma, COPD, heart problems, obesity, interstitial pulmonary fibrosis or certain lung conditions such as croup, traumatic lung injury, lung cancer, tuberculosis, pleurisy, pulmonary edema, pulmonary hypertension or sarcoidosis. In 2014, the American Thoracic Society (ATS) has proved that individuals with dyspnea, or shortness of breath have an increased long-term mortality risk compared with individuals without dyspnea.

Heart problems that can cause shortness of breath include cardiomyopathy, heart rhythm issues or pericarditis (inflammation of tissue that surrounds the heart). Obstructive lung diseases such as emphysema and chronic bronchitis may also cause breath issues. If the symptom continues for some time, it can also be an indication of some life-threatening conditions. In a healthy person, breath issues can be the result of very strenuous exercise, extreme temperatures or higher altitude.

The major symptom is labored breathing that may last for a few minutes after strenuous activity. Other signs include tightness in the chest, shortness of breath after exertion, rapid/shallow breathing, heart palpitations, wheezing, and coughing. Emergency medical treatment is necessary, if the symptoms include sudden onset of severe dyspnea, chest pain, nausea or loss of ability to function.

COVID-19 and Dyspnea

Shortness of breath or difficulty in breathing is also a possible symptom of COVID-19. CDC highlights that emergency warning signs for COVID-19 include trouble breathing, persistent pain or pressure in the chest, new confusion, inability to wake or stay awake and pale, gray, or blue-colored skin, lips, or nail beds, depending on skin tone. This symptom can persist and quickly escalate in people with COVID-19. Shortness of breath usually occurs a few days after initial infection. Some people may not develop this symptom at all. CDC reports that 31 to 40 percent of people with confirmed cases of COVID-19 have experienced shortness of breath. Those aged 65 or older, smokers, diabetic patients, COPD or patients with cardiovascular disease and those with a compromised immune system are at a higher risk for developing breathing issues with COVID-19.

ICD-10 Codes to Report Dyspnea

  • R06 Abnormalities of breathing
    • R06.0 Dyspnea
      • R06.00 Dyspnea unspecified
    • R06.01 Orthopnea
    • R06.02 Shortness of breath
    • R06.03 Acute respiratory distress
    • R06.09 Other forms of dyspnea

Rapid evaluation and diagnosis are crucial to reduce the burden of disease. Diagnosis may include a complete physical examination using X-rays and computed tomography (CT) images to evaluate the health of the person’s heart, lungs, and related systems, electrocardiogram (ECG) to find any signs of a heart attack, spirometry tests to measure airflow and the patient’s lung capacity or other tests to check the oxygen level in a patient’s blood. Treatment for dyspnea depends on the cause of the problem.

Medications such as bronchodilators and steroids may be recommended, if dyspnea is linked to asthma. For those with severe symptoms, supplemental oxygen will be provided. For infection related dyspnea, antibiotics provide relief. Other effective medications are – opiates, non-steroidal anti-inflammatory drugs (NSAIDs), and anti-anxiety drugs. Busy practices can consider teaming up with professional medical billing services in USA to submit clean claims and get on-time reimbursement.