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Question: A patient presented with an acute asthma exacerbation and the pulmonologist administered a nebulizer treatment in the office. Should I assign a symptom code for the treatment?

California Subscriber

Answer: No, you won’t assign a symptom code in the situation you’ve presented. Instead, you’ll assign an asthma code that relates to the patient’s chronic condition.

The J45.- (Asthma) code category features several codes and factors that you need to take into account when choosing the correct code. These factors include the type of asthma, patient’s condition, and the treatment’s efficacy.

Starting with the type of asthma, review the patient’s record to see if the provider issued one of the following diagnoses:

• Mild intermittent asthma
• Mild persistent asthma
• Moderate persistent asthma
• Severe persistent asthma

Next, you’ll check to see if the nebulizer treatment was successful in alleviating the patient’s symptoms. You’ll assign an acute exacerbation code if the treatment helped treat the asthma flare up, but if the patient didn’t respond to the treatment, you’ll assign a status asthmaticus diagnosis code.

Example: The provider documented the nebulizer treatment helped relieve the asthma symptoms of a patient who has moderate persistent asthma. In this case, you’ll assign J45.41 (Moderate persistent asthma with (acute) exacerbation) to report the diagnosis.

Mike Shaughnessy, BA, CPC, Development Editor I, AAPC