Pulmonology Coding Alert

Is severity the key to unlock a proper J45.- assignment? Find out.

Luckily, Pulmonology Coding Alert is here to help you separate fact from fiction for four remarkably relentless coding misconceptions related to these common pulmonology diagnoses.

Myth 1: Choose J45.2- If Your Pulmonologist Documents Mild Asthma

This is a myth that must be dispelled, as differences exist between J45.2- (Mild intermittent asthma) and J45.3- (Mild persistent asthma), which reflect an important clinical distinction that is key to documenting the severity of the patient’s condition.

“Clinical guidelines distinguish between intermittent and persistent asthma,” cautions Carol Pohlig, BSN, RN, CPC, manager of coding and education in the department of medicine at the Hospital of the University of Pennsylvania in Philadelphia. This means your pulmonologist 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).

There, you will see mild intermittent asthma, which means that the patient is experiencing symptoms twice a week or less and nighttime awakenings twice a month or less, is using a beta agonist inhaler such as albuterol for symptom control twice a week or less, and is experiencing no limitations on normal activity.

Mild persistent asthma, on the other hand, describes a more severe form of the condition 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.

Myth 2: There’s No Difference Between J45.3-, J45.4-, and J45.5- For a Persistent Asthma Diagnosis

Along the lines of the previous myth, each of the persistent asthma codes — J45.3-, J45.4- (Moderate persistent asthma), and J45.5- (Severe persistent asthma) — has clinical significance. Or, to put it another way, “a physician further classifies persistent asthma as mild, moderate, or severe,” according to Pohlig.

So, 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.

Important reminder 1: The medical documentation should call out distinctions in asthma severity as precisely as possible, as it will enable you to justify things, such as the office/ outpatient evaluation and management (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.

Myth 3: You Will Report Two Codes for Status Asthmaticus and Acute Asthma Exacerbation Diagnoses

This is a tricky myth to dispel, but once again, a little clinical knowledge will help you arrive at the most specific code possible.

Status asthmaticus is the most severe form of asthma because it “does not respond adequately to ordinary therapeutic measures and may require hospitalization,” according to Dorland’s Medical Dictionary. Knowing this tells you to “only code status asthmaticus if your provider documents both an acute exacerbation of asthma and status asthmaticus together, as status asthmaticus is the more severe condition,” according to Sherika Charles, CDIP, CCS, CPC, CPMA, compliance analyst with UT Southwestern Medical Center in Dallas.

So, no matter what asthma severity level your pulmonologist documents, if you see status asthmaticus in the note, you’ll automatically add the fifth character 2 to the code. Basically, you’ll use one code to report the two conditions together.

For example, a patient is diagnosed with an acute exacerbation of their moderate persistent asthma, status asthmaticus. In this case, you’ll assign J45.42 (Moderate persistent asthma with status asthmaticus) to report the diagnosis.

Important reminder 2: Most of the J45.- codes take an additional 5th character, which “helps to identify the patient’s current state and need for intervention,” explains Pohlig. The characters rise in severity. The 5th character 0 describes a patient who is experiencing no complications from the asthma. The 5th character 1, however, indicates that the patient is experiencing an acute exacerbation or “a worsening or decompensation of a chronic illness,” according to the ICD-10-CM Official Guidelines, Section C.10.a.1.