ICD 10 Coding Alert

Specialty Spotlight:

Bust These Pediatric Asthma Coding Myths

Published on Mon Oct 03, 2022

Hint: Understanding severity is crucial for coding asthma accurately.

There are some misunderstandings surrounding asthma diagnosis coding, but some clinical knowledge and a focus on ICD-10 guidelines can help coders get on the straight and narrow.

Check out these four persistent myths and pocket some expert advice for coding pediatric asthma.

Myth 1: You Can Choose Either J45.2- or J45.3- for ‘Mild’ Asthma

This is a myth that must be dispelled, as the difference between J45.2- (Mild intermittent asthma) and J45.3- (Mild persistent asthma) reflects an important clinical distinction that is key to documenting the severity of the patient’s condition.

“Clinical guidelines distinguish between intermittent and persistent asthma,” cautions Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania. This means your pediatrician will be following a classification system for asthma severity, such as the one provided by the National Heart, Lung, and Blood Institute (NHLBI) in their Asthma Care Quick Reference document (www.nhlbi.nih.gov/files/docs/guidelines/asthma_ qrg.pdf).

There, you will see mild intermittent asthma, which means that the patient is experiencing symptoms and nighttime awakenings twice a week or less, is using a beta agonist inhaler such as albuterol for symptom control twice a week or less, and is experiencing no limitations on normal activity.

Mild persistent asthma, on the other hand, describes a more severe form of the condition where a patient experiences symptoms more than two days a week but not daily, nighttime awakenings three to four times a month, uses a beta agonist more than two days a week but not daily, and experiences some limitations on normal activity.

Myth 2: You Can Choose J45.3-, J45.4- or J45.5- for ‘Persistent’ Asthma

Along the lines of the previous myth, each of the persistent asthma codes — J45.3-, J45.4- (Moderate persistent asthma) and J45.5- (Severe persistent asthma) — has clinical significance. Or, to put it another way, “a physician further classifies persistent asthma as mild, moderate, or severe,” according to Pohlig.

So, patients with moderate persistent asthma experience symptoms and use beta agonists on a daily basis, while patients suffering from severe persistent asthma do so on a frequent basis during the day. The relative severity of each condition means that patients are either limited in their activity levels, in the case of moderate persistent asthma, or very limited, in the case of severe persistent asthma.

Important reminder 1: You must be able to document distinctions in asthma severity as precisely as possible, as they will enable you to justify such things as the office/outpatient evaluation and management (E/M) level for a given patient encounter. Additionally, “having physicians document asthma to the best of their clinical ability will assist in preventing denials for E/M frequency or medical necessity,” Pohlig advises.

Myth 3: Never Code Both Acute Asthma Exacerbations and Status Asthmaticus

This is a tricky myth to dispel, but once again, a little clinical knowledge will help you arrive at the most specific code possible.

Status asthmaticus is the most severe form of asthma because it “does not respond adequately to ordinary therapeutic measures and may require hospitalization,” according to Dorland’s Medical Dictionary. Knowing this tells you to “only code status asthmaticus if your provider documents both an acute exacerbation of asthma and status asthmaticus together, as status asthmaticus is the more severe condition,” according to Sherika Charles, CDIP, CCS, CPC, CPMA, compliance analyst with UT Southwestern Medical Center in Dallas.

So, no matter what asthma severity level your pediatrician documents, if you see status asthmaticus in the note, you’ll automatically add the 5th character 2 to the code.

Important reminder 2: Most of the J45.- codes take an additional 5th character, which “helps to identify the patient’s current state and need for intervention,” explains Pohlig. The characters rise in severity. The 5th character 0 describes a patient who is experiencing no complications from the asthma. The 5th character 1, however, indicates that the patient is experiencing an acute exacerbation or “a worsening or decompensation of a chronic illness,” per ICD-10 Guideline C.10.a.1.

From this, you can deduce the 5th character 2 is the most severe of the conditions.

Myth 4: You Can Use ‘Other’ or ‘Unspecified’ Asthma Codes Interchangeably

This myth is also incorrect, as the J45.- codes are subject to the same ICD-10 guidelines regarding “Other” or “Unspecified” codes as any other ICD-10 code group. Simply stated, “codes titled ‘other’ or ‘other specified’ are for use when the information in the medical record provides detail for which a specific code does not exist,” while “codes titled ‘unspecified’ are for use when the information in the medical record is insufficient to assign a more specific code,” per ICD-10 Guidelines A.9.a and b.

So, “you would use the J45.99- [Other asthma] codes when the documentation states a type of asthma that doesn’t have a specific code,” explains Charles. This would include specified forms of asthma that are not described in the other categories, such as exercise-induced bronchospasm (J45.990)

Alternatively, “you would use a J45.90- [Unspecified asthma] code when your provider does not specify the type of asthma,” Charles adds.

Important reminder 3: If your pediatrician documents asthmatic bronchitis or childhood asthma, and there are no other, more specific codes you can use to document these conditions, you would assign an Unspecified code, as these conditions are listed as alternative terms for J45.90-.