R06.02
R06 — Abnormalities of breathing
Chapter 18: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (R00-R99)
R00-R09 — Symptoms and signs involving the circulatory and respiratory systems
Clinical Definition
Shortness of breath, clinically referred to as dyspnea, is the subjective sensation of difficulty breathing or an uncomfortable awareness of one's own breathing. It is one of the most common presenting complaints in both ambulatory and emergency medicine settings, with a differential diagnosis spanning pulmonary, cardiac, hematologic, neuromuscular, and psychiatric etiologies. Dyspnea may occur at rest or with exertion, and may be acute or chronic in nature. The symptom results from a mismatch between the brain's demand for ventilation and the body's ability to meet that demand.
ICD-10-CM code R06.02 is a symptom code specifically designated for shortness of breath. It is used when the provider documents 'shortness of breath,' 'SOB,' or 'dyspnea' as a clinical finding without establishing a definitive underlying diagnosis at the time of the encounter. This code is distinct from R06.00 (dyspnea, unspecified), R06.01 (orthopnea — dyspnea that occurs when lying flat), and R06.03 (acute respiratory distress — a more severe presentation). R06.02 should not be used when the shortness of breath has been definitively attributed to a specific underlying condition such as heart failure (I50.x), COPD (J44.x), asthma (J45.x), or pneumonia (J18.x), in which case the underlying diagnosis code takes precedence.
The clinical evaluation of shortness of breath includes a thorough history (onset, duration, exertional vs. resting, positional, associated symptoms), physical examination (respiratory rate, oxygen saturation, lung auscultation, cardiac examination, lower extremity edema), and targeted diagnostics (chest X-ray, ECG, BNP/NT-proBNP, pulse oximetry, ABG, CT angiography when PE is suspected, pulmonary function tests). Treatment depends on identifying and managing the underlying cause.
When to Use R06.02
- ✓The patient presents with shortness of breath or dyspnea and the provider documents this as a symptom without attributing it to a specific underlying diagnosis at the time of the encounter.
- ✓The patient is being evaluated for new-onset shortness of breath and the workup is in progress — no definitive diagnosis has been established yet.
- ✓The provider documents 'shortness of breath,' 'SOB,' or 'dyspnea' on the problem list or assessment without specifying a cause such as heart failure, COPD, or asthma.
- ✓Shortness of breath is documented as a presenting complaint for an emergency department or urgent care visit where the underlying cause is under investigation.
- ✓The patient reports exertional dyspnea during a routine visit and the provider documents the symptom for further evaluation without assigning a specific disease diagnosis.
Common Coding Mistakes
- ⚠Using R06.02 when the shortness of breath is definitively attributed to a known underlying condition — if the documentation states 'dyspnea due to COPD exacerbation,' code J44.1 (COPD with acute exacerbation) rather than R06.02.
- ⚠Using R06.02 when the documentation specifies orthopnea — use R06.01 (orthopnea) for dyspnea that specifically occurs in the recumbent position.
- ⚠Using R06.02 for acute respiratory distress — use R06.03 (acute respiratory distress) when the documentation specifies an acute, severe presentation of respiratory difficulty.
- ⚠Confusing R06.02 with R06.00 (dyspnea, unspecified) — R06.02 is the more specific code for 'shortness of breath' and should be used preferentially when the documentation supports it.
- ⚠Using R06.02 alongside the definitive diagnosis code for the same condition — when the underlying cause of the shortness of breath is established and coded, R06.02 is generally not reported separately unless it adds clinical information beyond what the disease code conveys.
Related & Differential Codes
| Code | Description | Relationship |
|---|---|---|
| R06.00 | Dyspnea, unspecified | Sibling |
| R06.01 | Orthopnea | Sibling |
| R06.03 | Acute respiratory distress | Sibling |
| R06.09 | Other forms of dyspnea | Sibling |
| R06.9 | Unspecified abnormalities of breathing | Sibling |
| J44.1 | Chronic obstructive pulmonary disease with acute exacerbation | Related |
| J45.20 | Mild intermittent asthma, uncomplicated | Related |
| I50.9 | Heart failure, unspecified | Related |
| I26.99 | Other pulmonary embolism without acute cor pulmonale | Related |
| J18.9 | Pneumonia, unspecified organism | Related |
| R07.9 | Chest pain, unspecified | Related |
| R09.02 | Hypoxemia | Related |
Documentation Requirements
- 1Characterization: specify the type of dyspnea — exertional, resting, paroxysmal nocturnal, positional — to determine whether R06.02 or a more specific code (R06.01 for orthopnea) is appropriate.
- 2Onset and duration: document whether the shortness of breath is acute, subacute, or chronic, and the timeframe of onset to guide the urgency of evaluation.
- 3Severity and functional impact: document the degree of limitation (e.g., dyspnea on exertion at what level of activity, dyspnea at rest) and any impact on activities of daily living.
- 4Associated symptoms: document concurrent symptoms such as chest pain, cough, wheezing, fever, lower extremity edema, palpitations, or anxiety that help narrow the differential.
- 5Objective findings: document respiratory rate, oxygen saturation (SpO2), lung auscultation findings (crackles, wheezing, diminished breath sounds), and cardiac examination findings.
- 6Diagnostic workup: document results of chest X-ray, ECG, BNP/NT-proBNP, pulse oximetry, ABG, CT angiography, or other studies performed to evaluate the dyspnea.
- 7Underlying cause if identified: when the workup reveals a specific etiology, document the underlying diagnosis to support transition from R06.02 to the definitive disease code.
Reimbursement & Billing Notes
ICD-10-CM code R06.02 is a valid, billable code accepted by Medicare, Medicaid, and commercial payers for encounters involving shortness of breath. It is one of the most commonly used symptom codes in emergency medicine and primary care, supporting medical necessity for diagnostic workup including chest X-ray, ECG, BNP, pulse oximetry, CT angiography (when PE is suspected), and pulmonary function tests. R06.02 is appropriate as a primary diagnosis when the underlying cause has not yet been determined.
R06.02 does not map to a CMS-HCC risk adjustment category. Once a definitive underlying diagnosis is established (heart failure, COPD, asthma, PE, etc.), that diagnosis code should be used for subsequent encounters instead of the symptom code. Payers may question continued use of R06.02 across multiple encounters if the clinical workup should have yielded a specific diagnosis. For quality reporting and risk adjustment purposes, coding the definitive diagnosis rather than the symptom code is preferred.
Auto-Code with DeepCura AI
DeepCura's AI medical scribe automatically captures clinical encounters and suggests accurate ICD-10 codes in real time — including R06.02 when clinically appropriate. Eliminate manual coding and reduce claim denials.
Try Free — No Credit Card RequiredFrequently Asked Questions
What is the ICD-10 code for shortness of breath?
The ICD-10-CM code for shortness of breath is R06.02. This symptom code is used when the provider documents shortness of breath, SOB, or dyspnea without attributing it to a specific underlying disease. It is the most specific code available for the symptom of shortness of breath within the R06 category.
What is the difference between R06.02 and R06.00?
R06.02 is the specific code for 'shortness of breath,' while R06.00 is 'dyspnea, unspecified.' Although shortness of breath and dyspnea are often used interchangeably in clinical practice, R06.02 is the more specific code and should be used when the documentation states 'shortness of breath' or 'SOB.' R06.00 is reserved for cases where dyspnea is documented without further specification.
When should I code R06.02 vs the underlying disease?
Use R06.02 when the shortness of breath is the presenting symptom and no underlying cause has been definitively diagnosed at the time of the encounter. Once a definitive diagnosis is established — such as heart failure (I50.x), COPD exacerbation (J44.1), asthma (J45.x), or pulmonary embolism (I26.x) — code the underlying disease rather than the symptom. The general ICD-10 coding guideline is that symptom codes are not reported alongside a definitive diagnosis that inherently includes that symptom.
What is the ICD-10 code for SOB on exertion?
Shortness of breath on exertion is coded as R06.02 (shortness of breath) in ICD-10-CM. There is no separate code that specifically distinguishes exertional dyspnea from resting dyspnea within the R06 category. The exertional nature should be documented in the clinical record to guide the diagnostic workup, even though the ICD-10 code does not capture that distinction.
Can R06.02 be used in the emergency department?
Yes, R06.02 is frequently used as the primary diagnosis in emergency department encounters. When a patient presents to the ED with shortness of breath and the evaluation is ongoing or inconclusive at the time of discharge, R06.02 is the appropriate primary diagnosis. If the ED workup establishes a specific cause (e.g., pneumonia, PE, heart failure exacerbation), that definitive diagnosis should be coded as the primary diagnosis instead.
What is the ICD-10 code for breathing difficulty?
For documented breathing difficulty or shortness of breath, use R06.02. For dyspnea that is further unspecified, use R06.00. For orthopnea (breathing difficulty when lying flat), use R06.01. For acute respiratory distress, use R06.03. The code selection depends on the specific terminology used in the clinical documentation.