Pediatric Coding Alert

Make sense of fifth digits to complete the picture.

Asthma is probably one of the most common conditions your pediatric practice diagnoses and treats. But no matter how familiar you are with the J45 (Asthma) code set, it's always a good idea to remind yourself what makes the codes so specific.

Coding different asthma conditions accurately is simple if you follow the National Heart, Lung and Blood Institute (NHLBI) guidelines for asthma diagnoses and know the fifth digit ICD-10 codes for each degree of severity.

So, take a deep breath, read on, and refresh your asthma coding knowledge.

First, Ask Intermittent or Persistent; Mild, Moderate or Severe

Unlike many ICD-10 codes, the J45 code set uses the severity of the symptoms rather than the etiology of the condition as its subdivisions. This is consistent with the current asthma guidelines determined by the NHLBI, which classifies the conditions this way.

The chart shows that the condition has four different states - mild intermittent, mild persistent, moderate persistent, and severe persistent - that correspond exactly with the following four code sets:

• J45.2, Mild intermittent asthma ...
• J45.3, Mild persistent asthma ...
• J45.4, Moderate persistent asthma ...
• J45.5, Severe persistent asthma ...

A fifth code, J45.9 (Other and unspecified ...) is reserved for forms of the condition that do not fit neatly into the established categories, such as asthmatic bronchitis, childhood asthma, or exercise-induced bronchospasm.

Then, Add 0, 1, or 2 for Full Reimbursement

Each of the four code sets subdivide to describe the severity more specifically. For example, J45.2 expands into the following three subsets:

• J45.20, Mild intermittent asthma, uncomplicated
• J45.21, ... with [acute] exacerbation
• J45.22, ... with status asthmaticus

As with the main code sets, the higher the number, the more severe the condition. So, you would document the most severe form of an asthma attack, status asthmaticus, with the highest fifth digit, 2. (The J45.90 code set, however, features an exception to that rule, reserving 9 as the sixth digit when the condition is uncomplicated.)

This degree of precision is critical for asthma coding. Donelle Holle, RN, President of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana, notes that "many providers fail to use asthma codes to the highest level of specificity.  Using unspecified asthma codes may cause a decrease in reimbursement in the future due to risk management regarding diagnosis coding."

And Chip Hart, director of PCC's Pediatric Solutions Consulting Group in Vermont and author of the blog "Confessions of a Pediatric Practice Consultant," offers the reminder that you should "use the J45 codes properly and often. Pediatric clinical quality measures [CQMs] trigger off the 'persistent' asthma diagnoses, and if you use the unspecified, cough variant, or other options, you may not get credit for some important measures."

Scenario: Your provider assesses a patient with asthma who is currently experiencing episodes of acute exacerbation. The patient suffers from symptoms at least twice a week, limiting the patient's daily activities somewhat. The patient also uses an inhaler more than twice a week, but not on a daily basis. Based on these symptoms, and the results of a pulmonary function test (PFT) that records a forced expiratory volume in 1 second (FEV1) >80%, your provider diagnoses an acute exacerbation of a mild persistent type of asthma.

This would make J45.31 (Mild persistent asthma with [acute] exacerbation) the correct diagnosis in this scenario.

Holle notes that "the use of an additional code such as Z72.0 (Tobacco use), F17- (Nicotine use...), or Z77.22 (Contact with and [suspected] exposure to environmental tobacco smoke [acute] [chronic]) is very important if there is an exposure to smoke or if the patient smokes - and some teens do!"

And, outside of the ICD-10-CM codes, Hart cautions that "too many practices just toss an evaluation and management [E/M] code, such as 99213 (Office or other outpatient visitfor the evaluation and management of an established patient ...) at those visits and walk away. Don't forget to bill codes such as 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction ...) and others as appropriate."