Pulmonology Coding Alert

Question: A patient presented to the emergency department (ED) with a flare up of their moderate persistent asthma. The patient was wheezing and having trouble breathing. Pulmonology was consulted. The documentation states the patient tried to use their regular inhaler at home, but they didn’t respond to the therapy. The pulmonologist administered an asthma nebulizer to treat the symptoms and administered methylprednisolone. The patient was stabilized, and the provider diagnosed the patient with status asthmaticus.

What codes should I report for the diagnosis?

New York Subscriber

Answer: You’ll assign J45.42 (Moderate persistent asthma with status asthmaticus) to your claim. Status asthmaticus describes a patient who fails to respond to treatment after an acute exacerbation of asthma.

The patient has a history of moderate persistent asthma, so using the status asthmaticus combination code listed within the J45.4 (Moderate persistent asthma) code subcategory is the correct choice.

According to the ICD-10-CM Official Guidelines, section I.C.10.a.1, “an acute exacerbation is a worsening or decompensation of a chronic condition.” The acute exacerbation may be triggered by an infection, but it isn’t the same as when an infection occurs on top of a chronic condition.

Mike Shaughnessy, BA, CPC, Development Editor, AAPC