ICD 10 Coding Alert

Here's how to avoid that note in your report that says 'I need more information.'

Are you simply documenting "asthma?" That's not enough for ICD-10-CM. Find out how you need to brush up on your asthma lingo to maximize your coder's choice and increase your bottom line.

Danger: Remember, if you don't document asthma severity, then your coder has to choose J45.998 (Other asthma). Submitting this multiple times could red flag your practice for an audit.

Use These Key Terms for Asthma Severity

The ICD-10-CM codes will include the following terminology:

• "Intermittent"
• "Mild persistent"
• "Moderate persistent"
• "Severe persistent"

You can break down what these terms really mean by examining this chart:

(National Heart, Lung, and Blood Institute. Accessed: May 20, 2010. Expert Panel Report 3 (EPR3): Guidelines for the Diagnosis and Management of Asthma. URL: www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm)

Documentation advancement: You can state "the patient experiences asthma symptoms daily and uses his rescue inhaler daily," which would direct the coder to moderate persistent asthma. Or you can make it easy on your coder by simply saying "the patient has moderate persistent asthma."

Take action: Although ICD-10-CM does not go into effect in October 2013, you can still start increasing your documentation's specificity. Start going in-depth with your patient's asthma symptoms. Your goal is to avoid any unspecified codes, due to lack of documentation.

Here are your possible asthma variations:

• J45.20 -- Mild intermittent asthma, uncomplicated
• J45.21 -- Mild intermittent asthma with (acute) exacerbation
• J45.22 -- Mild intermittent asthma with status athmaticus
• J45.30 -- Mild persistent asthma, uncomplicated
• J45.31 -- Mild persistent asthma with (acute) exacerbation
• J45.32 -- Mild persistent asthma with status asthmaticus
• J45.40 -- Moderate persistent asthma, uncomplicated
• J45.41 -- Moderate persistent asthma with (acute) exacerbation
• J45.42 -- Moderate persistent asthma with status asthmaticus
• J45.50 -- Severe persistent asthma, uncomplicated
• J45.51 -- Severe persistent asthma with (acute) exacerbation
• J45.52 -- Severe persistent asthma with status asthmaticus
• J45.901 -- Unspecified asthma with (acute) exacerbation
• J45.902 -- Unspecified asthma with status asthmaticus
• J45.990 -- Exercise induced bronchospasm
• J45.991 -- Cough variant asthma
• J45.998 -- Other asthma.