Primary Care Coding Alert

Look for advice on how to handle proper sequencing.

Now that winter is officially here, if you feel like your asthma coding knowledge could use a little TLC, keep reading.

Why is winter prime time for this refresher? Asthma sufferers often dread when the weather turns colder. Cold, dry air, or simply sudden shifts in the weather, can increase mucus production, which wreaks havoc on airways. Staying indoors isn’t always the answer because that can put people in closer contact with cold and flu viruses, which also are troublesome for asthmatics.

Know the Difference Between ‘Intermittent’ and ‘Persistent’

Severity is always a key question when it comes to asthma. The physician is going to need to understand the extent of a patient’s symptoms and the condition in general, which will not only affect their care (and coding requirements) but also could potentially affect how you level the evaluation and management (E/M) service.

“Clinical guidelines distinguish between intermittent and persistent asthma,” cautions Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania. This means your primary care physician will be following a classification system for asthma severity such as the one 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).

Asthma has four different states of severity — intermittent, mild persistent, moderate persistent, and severe persistent — that correspond with the first four code subgroups in the J45.- group:

• J45.2- (Mild intermittent asthma)
• J45.3- (Mild persistent asthma)
• J45.4- (Moderate persistent asthma)
• J45.5- (Severe persistent asthma)

Most of the codes in this group require that 5th character to communicate the patient’s state at the time of the encounter. Adding a 0 as the 5th character signifies no complications and adding a 1 for “(acute) exacerbation” signifies the patient’s condition is getting worse or experiencing a decompensation, per ICD-10-CM Official Guidelines, Section I.C.10.a.1. If you add a 2, that means status asthmaticus, which is the most severe form of asthma and will likely require hospitalization.

Beware of “Mild”: With asthma, the word “mild” doesn’t always mean what it might for other conditions. For example, when you see the physician has documented that the patient over 5 years of age suffers mild intermittent asthma, that means the patient is experiencing symptoms twice a week or less, nighttime awakenings twice a month or less, and is using a beta agonist inhaler, such as albuterol, for symptom control twice a week or less. But a patient with mild persistent asthma suffers a considerably more severe form of asthma, with symptoms more than two days a week (not daily), nighttime awakenings three to four times a month, uses a beta agonist more than two days a week, but not daily and not more than once on any day. Additionally, the patient experiences minor limitations on normal activity.

E/M alert: Documenting distinctions in asthma severity as precisely as possible will facilitate justifying choices such as the office/outpatient E/M level for a given patient encounter. Additionally, “having physicians document asthma to the best of their clinical ability will assist in preventing denials for E/M frequency or medical necessity,” Pohlig advises.

Pay Attention to Documented Triggers

To properly code a patient’s asthma, look for words that describe the agents that trigger the condition. Allergic asthma for example, is often called extrinsic; when you see that term in the notes, it means the patient is diagnosed with asthma that’s caused by an allergic reaction. Most often, extrinsic asthma means a chronic allergic reaction. Intrinsic asthma, on the other hand, is nonallergic and can be triggered by cold, dry air, smoke, stress, anxiety, and a host of other things.

Whether you’re coding a diagnosis of extrinsic allergic asthma or intrinsic nonallergic asthma, you’ll assign a code from the J45.- category. The parent code features an Includes note that contains extrinsic allergic asthma and intrinsic nonallergic asthma synonyms.

Parent code J45.- also features instructions to use an additional code to identify certain triggers of asthma exacerbation, such as exposure to tobacco smoke. Beyond that, there’s value in identifying the cause when the asthma is exacerbated. “If there is an exacerbation, providers should identify the cause. This will require two codes: one to specify the type of asthma and one for the allergy or other cause of exacerbation,” says Sheri Poe Bernard, CPC, CRC, CDEO, CCS-P, CPC-I, managing consultant at Granite GRC Consulting and CEO of Prestige CEUs in Salt Lake City, Utah.

Solidify Your Understanding of Sequencing

Following from the previous example, you also need to consider the importance of proper sequencing when dealing with asthma coding. For example, if your provider evaluated a patient with moderate persistent asthma experiencing an exacerbation due to a peanut allergy, then you’ll assign two codes for the diagnosis. The codes you’d assign would be J45.41 (Moderate persistent asthma with (acute) exacerbation) and Z91.010 (Allergy to peanuts).

On the other hand, if the same patient was experiencing an exacerbation of their asthma due to acute bronchitis from a parainfluenza virus infection, then you’d assign J20.4 (Acute bronchitis due to parainfluenza virus) as the second code.

Heed the Excludes2 note: You’ll see that J45 directs you to code to J44.9 when the patient has asthma with chronic obstructive pulmonary disease, chronic asthmatic (obstructive) bronchitis, or chronic obstructive asthma (J44.9). These are all distinct from chronic asthma, which is still coded to J45.-.

Review the Difference Between ‘Unspecified’ and ‘Other’

Remember that the J45.- codes are subject to the same ICD-10 guidelines regarding “other” or “unspecified” codes as any other ICD-10 code group. Simply stated, “codes titled ‘other’ or ‘other specified’ are for use when the information in the medical record provides detail for which a specific code does not exist,” while “codes titled ‘unspecified’ are for use when the information in the medical record is insufficient to assign a more specific code,” per ICD-10 guidelines I.A.9.a and b.