Pediatric Coding Alert

Question: Our pediatrician diagnosed a patient with mild asthma and described the patient as experiencing symptoms twice a week. The patient uses an albuterol inhaler no more than twice a week, and the condition does not hinder normal daily functions. I’m not sure which code to report. Do these symptoms classify the patient’s mild asthma as persistent or intermittent?

Wisconsin Subscriber

Answer: Based on the documented symptoms, the correct code to report is J45.2- (Mild intermittent asthma). Here’s how you can tell the difference between J45.2- and J45.3- (Mild persistent asthma).

Severity of the condition, as you know, is what determines the correct diagnosis. Your pediatrician did not specifically write “mild intermittent asthma” in the medical notes, but they did appropriately document the symptoms that correspond to the classification system for asthma severity as 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 that a patient experiencing mild intermittent asthma suffers symptoms and nighttime awakenings twice a week or less, uses a beta agonist inhaler such as albuterol for symptom control twice a week or less, and experiences no limitations on normal activity. This definition matches your provider’s description of the patient’s symptoms almost word-for-word, making it clear that the patient has mild, intermittent asthma, coded to J45.2-.

Mild persistent asthma, on the other hand, is a more severe form of mild asthma 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.

As always, if ever the notes appear discrepant or incomplete, query the provider for additional information.