ED Coding and Reimbursement Alert

Question: An adolescent patient presented to our ED with asthma-like symptoms: coughing, wheezing, and shortness of breath. Our physician recorded a diagnosis of reactive airways dysfunction syndrome, or RADS. However, I cannot find an ICD-10-CM code to document this - the closest I can get in the index is reactive airways disease (RAD), but even that doesn't have a code. How should I go about reporting this?

Codify Subscriber

Answer: Neither RADS nor RAD (the term recognized in ICD-10-CM) is associated with a code. Instead, the entry for RAD in the ICD-10-CM index simply states, "see Asthma."

As ICD-10-CM explicitly links RAD with asthma, you can only look to the J45- (Asthma) codes to find your answer. This automatically rules out other possibilities, such as J98.01 (Acute bronchospasm) or J98.9 (Respiratory disorder, unspecified). So, J45.909 (Unspecified asthma, uncomplicated) is the best fit given the nature of the disease.

Coding alert: If your physician is reluctant to provide a diagnosis of asthma, you could possibly confer with her and see if a complaint- or symptom-based diagnosis is more appropriate. In that case, you could go ahead and use codes such as R06.2 (Wheezing) and R06.02 (Shortness of breath) instead.