Primary Care Coding Alert

And don’t forget cause/effect sequencing.

This past January, the Centers for Disease Control and Prevention (CDC) released its midyear code set updates for the 2024 ICD-10 code set. Even though the code set updates don’t include any new or revised asthma codes, there is a change to be aware of when coding for it.

As spring marches on, and allergens continue to wreak havoc, now is the perfect time to brush up on your skills. Keep reading for details on this update as well as clarification on the most common asthma coding conundrum: sequencing.

Understand the Coding Update

Background: Each year, the National Center for Health Statistics (NCHS) creates updated ICD-10-CM files under the authorization of the World Health Organization (WHO). The files that are effective on April 1 of the current year replace the files implemented on Oct. 1 of the previous calendar year. Among the 2024 midyear updates is a change in Chapter 10, which affects the Excludes2 note under parent code J45.- (Asthma). So, while the update is not directly related to coding straight-up asthma, it is related to how you report asthma alongside other common comorbid conditions.

Details: Previous to the update, you’ve been assigning J44.89 (Other specified chronic obstructive pulmonary disease) instead of J44.9 (Chronic obstructive pulmonary disease, unspecified) if the patient is also experiencing any of the following conditions:

• Asthma with chronic obstructive pulmonary disease
• Chronic asthmatic (obstructive) bronchitis
• Chronic obstructive asthma

Now, ICD-10 has added “Other specified chronic obstructive pulmonary disease” to the list above in the J45.- Excludes2 note.

Note: It’s common for a patient with asthma to have one or more co-existing conditions. These additional conditions can complicate the management of the asthma and may also influence the severity and control of the disease. This is why it’s important to pay close attention to all Excludes2 notes, which indicate that two or more conditions may exist at the same time. Remember that you may report the conditions together if the provider has documented them, but you must also report them in the proper order on the claim.

Secure Your Sequencing Skills for Asthma Triggers

In addition to Excludes2 instructions associated with parent code J45.- , you’ve likely also noticed the use additional code note to identify certain triggers of asthma exacerbation. According to Sheri Poe Bernard, CPC, CRC, CDEO, CCS-P, CPC-I, managing consultant at Granite GRC Consulting in Salt Lake City, Utah, “The cause and effect of asthma must be documented and coded. Providers should document the asthma by its severity and chronicity, and the presence of the exacerbation.”

Example: A patient comes in experiencing exacerbation of their moderate persistent asthma due to acute bronchitis from a parainfluenza virus infection. How would you sequence the codes?

According to the ICD-10 guidelines, you’re to list the asthma code first, followed by the code for the trigger. Therefore, for this case, you should assign J45.41 (Moderate persistent asthma with (acute) exacerbation) first, and then J20.4 (Acute bronchitis due to parainfluenza virus) as the second code.

Excludes1 alert: Always make sure you’re also adhering to Excludes1 notes when reporting comorbid conditions. For example, if you’re trying to report J30.1 (Allergic rhinitis due to pollen) with J45.909 (Unspecified asthma, uncomplicated), you’ll see the Excludes1 note with J30.- instructing you to code to J45.909 exclusively if the patient suffers allergic rhinitis with asthma (bronchial).

Remember the Reason for the Encounter

Reporting the cause and effect of the condition is important, but it’s also important to consider the reason for the encounter.

Example: If a patient with chronic asthma comes in, and the provider diagnoses them with a cold but also prescribes a steroid inhaler to address the asthmatic cough that’s been exacerbated by the cold, you would want to report both conditions. However, unlike the example above, you’ll need to report the cold first, and the asthma second. The payer will likely deny the claim unless the cold is listed as the primary reason for the encounter.

The chronic asthma in this case impacts treatment like any comorbid condition. Therefore, in this case, you’d report J00 (Acute nasopharyngitis [common cold]), then list J45.901 (Unspecified asthma with (acute) exacerbation) as the second code.

Don’t Downplay the Importance of Documentation

As always, make sure you’re reporting the codes that not only represent the diagnoses but also reflect everything that happened during the encounter. In other words, if the

patient has controlled asthma, but the provider didn’t document its relationship to anything that happened during the encounter, the payer is going to undoubtedly question the asthma code. The provider must also be clear in how each additional condition is linked to the asthma. “The exacerbation must be described and linked to the hay fever, and a separate code for the hay fever should be reported,” says Bernard.

Let’s look at an example.

Example: An established patient with a history of moderate persistent asthma presents to the clinic complaining of rhinorrhea, itchy nose, watery eyes, and shortness of breath. The patient’s neighbor had been mowing their lawn, and the patient’s asthma flared up. This patient has previously undergone allergy testing, which confirmed a positive reaction to grass pollen. The patient’s asthma symptoms have historically worsened during this season and improve with the treatment of hay fever. The provider diagnoses the patient with an acute exacerbation of moderate persistent asthma due to hay fever.

In this note, the physician has referenced several details that support the diagnosis as well as the link between the hay fever and the asthma. Therefore, you’ll need to submit two ICD-10 codes to report the diagnosis. You’ll assign J45.41 (Moderate persistent asthma with (acute) exacerbation) for the patient’s asthma exacerbation first, then. report the cause of the asthma attack with J30.1 (Allergic rhinitis due to pollen). Among J30.1’s additional synonyms you’ll find hay fever, which is the provider’s documented diagnosis.