Before assigning codes for Asthma, you just raise the below questions and extract the answers from the medical documentation. These questions will definitely help you to pick up the right codes to a greater specificity with any additional codes, if applicable.
Questions to ask yourself when coding Asthma condition:
1. What is the Severity of Asthma?
2. What is the complication status?
3. Is there any exposure to tobacco use?
4. Any associated respiratory condition like COPD and bronchitis are documented?
Before we dive into the coding topic, let’s look at the definition and the symptoms of Asthma condition which would help in the proper code assignment.
Asthma is a chronic lung disease that inflames and narrows the airways in the lungs and can make breathing difficult. It also triggers coughing, wheezing and shortness of breath that contributes to the subjective symptoms of Asthma condition.
Asthma can’t be cured but its symptoms can be controlled under medications like inhaled corticosteroids, long-acting and short-acting beta agonists and other combination inhalers. Although the actual cause of asthma is unclear, risk factors that may lead to asthma includes having another allergic condition, obesity, use of tobacco (first or second hand), gestational exposure to tobacco, exposure to fumes or pollution, occupational exposure to triggers, exposure to certain germs or parasites, and or some types of bacterial or viral infections.
What is the Severity of Asthma?
Asthma codes are classified based on the severity of the condition. It includes mild, moderate or severe and whether the patient has intermittent or persistent Asthma.
What is the complication status?
The complication status is identified by the fifth character in the code category as acute exacerbation, status asthmatics, and uncomplicated.
0 – uncomplicated
1 – with acute exacerbation
2 – Status asthmatics
Acute exacerbation of Asthma: An acute exacerbation of asthma, often referred to as an “asthma attack,” is an acute or sub-acute episode of progressive worsening of symptoms of asthma including shortness of breath, wheezing and cough. Usually the symptoms can be reduced with home treatment using the fast acting bronchodilators.
Status asthmatics: It is described as asthma with acute symptoms that do not respond to standard treatment including the use of steroids and bronchodilators.
Is there any exposure to tobacco use?
ICD-10 CM has instructional notes that direct the coders to use additional codes to identify any tobacco exposure and/or use.
Any associated respiratory condition like COPD and bronchitis are documented?
Often Asthma is seen in patients who also have chronic obstructive disease (COPD). ICD-10 CM has an instructional code that tells you when you need to report both the conditions together.
COPD and Asthma – with specification of Asthma type – Code both COPD and Asthma
If patients have both Asthma and COPD documented, with the specification of type of asthma provided, then you need to report both codes.
Example: Documentation has COPD and moderate persistent Asthma.
Code assignment: J44.9 – Chronic obstructive pulmonary disease, unspecified
J45.40 – Moderate persistent asthma, uncomplicated
In this example, both the Asthma with its specific type (moderate persistent) and COPD are documented. Therefore we need to assign two codes.
Asthma and COPD – without specification of Asthma type – Code only COPD
If patients have COPD and asthma documented, without any further specificity of the type of asthma, only COPD would be reported. Unspecified asthma is not a specific type of asthma. Therefore no additional codes would be assigned for unspecified asthma.
Happy learning! Happy Coding!