Pediatric Coding Alert

Use this guide to capture conditions correctly.

You know that the J45.- (Asthma) codes are broken down into four distinct states: mild intermittent, mild persistent, moderate persistent, and severe persistent. But do you how to differentiate between the different levels of severity? Or between uncomplicated conditions and status asthmaticus?

Coding to the highest degree of specificity is important for any condition, but for asthma, it is vital. So, here are some great pieces of advice and some coding tips for you to take and sharpen your asthma coding skills.

Know How Asthma Conditions Are Broken Down

“Physicians diagnose asthma according to the frequency, duration, and extent of patient symptoms and electing the correct diagnosis for asthma is heavily weighted on the physician’s assessment and documentation,” says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania. “Clinical guidelines distinguish between intermittent and persistent asthma and vary by age. A physician further classifies persistent asthma as mild, moderate, or severe,” Pohlig reminds coders.

Pro coding tip 1: You can view the clinical guidelines for the different states in a severity chart such as the one contained in the Asthma Care Quick Reference document found at www.nhlbi.nih.gov/files/docs/guidelines/asthma_qrg.pdf.

Know the Difference Between Mild Intermittent and Mild Persistent

Even though both conditions contain the word “mild,” there is a big difference between them. Coding J45.2- (Mild intermittent asthma) 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, is more severe. A patient diagnosed with J45.3- (Mild persistent asthma) 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.

Know the Difference Between Moderate and Severe Persistent

As if knowing the difference between mild intermittent and mild persistent asthma wasn’t confusing enough, knowing the difference between the different persistent asthma conditions can be just as difficult. Fortunately, the same components that apply to the milder forms of the condition can be used to determine the different levels of severity for J45.4- (Moderate persistent asthma) and J45.5- (Severe persistent asthma).

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 the case of moderate persistent asthma, or very limited, in the case of severe persistent asthma, in their activity levels.

Know When, How, and Why to Code Acute Exacerbation

Most of the J45.- codes take an additional fifth digit, which “helps to identify the patient’s current state and need for intervention,” explains Pohlig.

Adding the fifth digit 0 means that the patient is experiencing no complications from the asthma. Adding a 1, however, means that the patient is experiencing “a worsening or decompensation of a chronic illness” according to ICD-10 guidelines.

This means that “the physician is best able to justify the provision of a nebulizer treatment in the office when the reported diagnosis identifies the patient is having an acute exacerbation rather than the condition being ‘uncomplicated,’” Pohlig continues.

Know When, How, and Why to Code Status Asthmaticus

Another fifth digit, 2, is reserved for status asthmaticus, the most severe form of the condition that “does not respond adequately to ordinary therapeutic measures and may require hospitalization,” according to Dorland’s Medical Dictionary.

Pro coding tip 2: “If your provider documents both an acute exacerbation of asthma and status asthmaticus together, you should only code status asthmaticus as it is the more severe condition,” Sherika Charles, CDIP, CCS, CPC, CPMA, compliance analyst with UT Southwestern Medical Center in Dallas, Texas, reminds coders.

Know When, How, and Why to Code “Other” or “Unspecified”

One other set of codes, J45.9- (Other and unspecified asthma) may also factor into your reporting.

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

“You would use the ‘unspecified’ [J45.90-] when your provider does not specify type of asthma,” Charles adds.

Pro coding tip 3: As the J45.90- codes go to six digits, you would use the acute exacerbation, 1, or the status asthmaticus, 2, designations as a sixth digit when appropriate. ICD-10 also adds a further sixth-digit designation, 9, for uncomplicated forms of the conditions in this code set.

Teachable moment: Work with your providers to help them understand these nuances to coding the condition. “Having physicians document asthma to the best of their clinical ability will assist in preventing denials for frequency or medical necessity,” Pohlig advises.