Primary Care Coding Alert

Condition Spotlight:

Take These 4 Steps to Improve Your Asthma Coding Accuracy

And code this scenario to bring it all home.

Though asthma triggers can occur at any time of year, winter can be an especially difficult time for sufferers. Cold, dry air irritates the lungs’ airways, worsening symptoms, while the prevalence of colds and flu during the winter months can make breathing difficulties even worse.

That means now is a good time to refresh your memory about how to use the J45.- (Asthma) codes. So, we’ve broken them down to make your life just a little easier.

Step 1: Determine Severity

While “the correct diagnosis for asthma is heavily weighted on the physician’s assessment and documentation, clinical guidelines distinguish between intermittent and persistent asthma, so physicians diagnose asthma according to the frequency, duration, and extent of patient symptoms,” says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania.

This means the first step toward correct asthma coding lies in understanding those clinical guidelines, which you can see in a chart such as the one produced by the National Heart, Lung, and Blood Institute (NHLBI) below.

Source: (NHLBI. Guidelines for the Diagnosis and Management of Asthma (EPR-3) www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm).

The chart shows that the condition has four different states of severity — intermittent, mild persistent, moderate persistent, and severe persistent — that correspond with the first four codes in the J45.- group:

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

Step 2: Use Fifth Digit to Specify Current State

Most of the J45.- codes then 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 “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.

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.

Coding alert: “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.

Step 3: Understand When to Code “Other” or “Unspecified

You should use the last group of J45.- codes — J45.9- (Other and unspecified asthma) — sparingly. That’s because, as with many other conditions, “having physicians document asthma to the best of their clinical ability will assist in preventing denials for frequency or medical necessity,” Pohlig advises.

So, you will want to avoid using J45.90- (Unspecified asthma) in particular and try to help your provider determine a more specific code when possible.

The J45.99- (Other asthma) codes present similar problems. Even though they do point to specified forms of asthma that are not described in the other categories, such as exercise-induced bronchospasm (J45.990) or cough variant asthma (J45.991), “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,” cautions Chip Hart, director of PCC’s Pediatric Solutions Consulting Group in Vermont and author of the blog “Confessions of a Pediatric Practice Consultant.”

Step 4: Don’t Forget These Additional Codes

Once you have determined the most specific asthma code, ICD-10 also requires you to use an additional code to identify tobacco use, dependence, or exposure when appropriate, as they are powerful triggers for the condition. So, look for documentation of such conditions as Z77.22 (Contact with and (suspected) exposure to environmental tobacco smoke (acute) (chronic)), F17.- (Nicotine dependence), or Z87.891 (Personal history of nicotine dependence) for complete asthma reporting.

Putting it All Together

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 mild persistent type asthma.

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