Pediatric Coding Alert

Question: My pediatrician documented that the patient has persistent asthma. Does that mean I should report J45.3-, J45.4- or J45.5-?

Florida Subscriber

Answer: The asthma codes can be tough because there are several classifications, such as mild, moderate, and severe, coded to J45.3- (Mild persistent asthma), J45.4- (Moderate persistent asthma) and J45.5- (Severe persistent asthma). Before selecting the code for a patient’s persistent asthma, you first need to know how the physician has classified the condition. This means that which code you select depends on additional details in the documentation.

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. These details will likely be in the patient record, but be sure to check with the pediatrician.

Reminder: 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.