Otolaryngology Coding Alert

Question: An established patient with a history of moderate persistent asthma presented to the clinic complaining of rhinorrhea, itchy nose, watery eyes, and shortness of breath. The patient’s neighbor had been mowing their lawn, and the patient’s asthma flared up. The provider diagnosed the patient with an acute exacerbation of moderate persistent asthma due to hay fever.

How should this be coded? Do we need cause-and-effect coding for asthma exacerbation?

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Answer: You will always code the cause of an asthma exacerbation if the provider documents it in the medical record.

According to Sheri Poe Bernard, CPC, CRC, CDEO, CCS-P, CPC-I, managing consultant at Granite GRC Consulting in Salt Lake City, Utah, “The cause and effect of asthma must be documented and coded. Providers should document the asthma by its severity and chronicity, and the presence of the exacerbation or if the condition is status asthmaticus.”

In this case, you’ll use two ICD-10 codes to report the diagnosis: “The exacerbation must be described and linked to the hay fever, and a separate code for the hay fever should be reported,” Bernard says.

Assign J45.41 (Moderate persistent asthma with (acute) exacerbation) for the patient’s asthma exacerbation. Next, report the cause of the asthma attack with J30.1 (Allergic rhinitis due to pollen). Among J30.1’s additional synonyms you’ll find hay fever, which is the provider’s documented diagnosis.

Critical: Though the scenario focuses on a worsening of “moderate persistent asthma,” a patient may present with more severe symptoms that may fall under the helm of “status asthmaticus.”

Definition: Status asthmaticus is an asthma attack that doesn’t improve with traditional treatments, such as inhaled bronchodilators — and the ICD-10 code associated with this life-threatening type of asthma flare-up is J45.52 (Severe persistent asthma with status asthmaticus).

Signs and symptoms: A patient experiencing status asthmaticus may have difficulty breathing, be panicked, confused, unable to talk in complete sentences, or even have a bluish tint to their lips. The condition requires urgent medical attention, as these signs can be indicative of respiratory failure.