Coding case studies: Asthma

Getting paid requires accurate documentation and selecting the correct codes. In our Coding Case Studies, we will explore the correct coding for a specific condition based on a hypothetical clinical scenario. Check out the following scenario involving a patient presenting with asthma and see if you can choose the correct codes.

Clinical Scenario

Chief complaint: Asthma exacerbation

History

6-year-old boy, established patient.

Mother says son has had an exacerbation of asthma symptoms during their family vacation to a dude ranch in Arizona last week. Mother says that there was a lot of secondhand smoke at the ranch.

Mother says the albuterol inhaler was last used this morning, about 90 minutes prior to arrival, but seems less effective than usual. Father also has asthma.

Exam

Vital Signs:

BP: 110/67

HR: 100

T: 98.9°F

R: 28

Wt.: 25kg

SpO2: 95%

General appearance: mild respiratory distress, alert.

ENT: oropharynx clear, no plaques or exudates, minimal nasal flaring noted, no accessory muscle use.

Respiratory: diminished breath sounds with mild expiratory wheezing heard throughout.

Cardiovascular: no murmurs, no rubs, no gallops.

Assessment and Plan

Intermittent asthma with acute exacerbation caused by exposure to second hand smoke

Nebulizer treatment given, with improvement; 3-day course of oral prednisone

Family history of asthma

Documentation Coding Requirements

How should this be coded? Here is some background information on documentation requirements and the available ICD-10 codes. When documenting asthma, include the following:

Cause

Exercise induced, cough variant, related to smoking, chemical or particular cause, occupational

Severity

Choose one of the three options below for persistent asthma patients

• Mild persistent
• Moderate persistent
• Severe persistent

Temporal Factors

Acute, chronic, intermittent, persistent, status asthmaticus, acute exacerbation

Asthma ICD-10 Codes

J45.20 Mild intermittent asthma, uncomplicated

J45.21 Mild intermittent asthma with (acute) exacerbation

J45.22 Mild intermittent asthma with status asthmaticus

J45.30 Mild persistent asthma, uncomplicated

J45.31 Mild persistent asthma with (acute) exacerbation

J45.32 Mild persistent asthma with status asthmaticus

J45.40 Moderate persistent asthma, uncomplicated

J45.41 Moderate persistent asthma with (acute) exacerbation

J45.42 Moderate persistent asthma with status asthmaticus

J45.50 Severe persistent asthma, uncomplicated

J45.51 Severe persistent asthma with (acute) exacerbation

J45.52 Severe persistent asthma with status asthmaticus

J45.901 Unspecified asthma with (acute) exacerbation

J45.902 Unspecified asthma with status asthmaticus

J45.909 Unspecified asthma, uncomplicated

J45.990 Exercise induced bronchospasm

J45.991 Cough variant asthma

J45.998 Other asthma

Diagnosis Code

J45.21

Mild intermittent asthma, with (acute) exacerbation main reason for visit, so listed as primary diagnosis.

Z82.5

Family history of asthma and other chronic lower respiratory diseases.

Z77.22

Contact with and (suspected) exposure to environmental tobacco smoke (acute) (chronic). Per ICD-10 guidelines for asthma and other respiratory diseases, additional required code for history of tobacco use, or current use of or dependence on tobacco, when applicable.