Coding Case Study: Documenting and coding 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 with asthma and see if you can choose the correct codes.

First, some background information on documentation requirements and the available ICD-10 codes.

Documentation Coding Requirements

When documenting asthma, include the following:

1. Cause  Exercise-induced, cough variant, related to smoking, chemical or particulae cause, occupational

2. Severity Choose one of the three options below for persistent asthma patients

1. Mild persistent

2. Moderate persistent

3. Severe persistent

3. Temporal Factors Acute, chronic, intermittent, persistent, status asthmaticus, acute exacerbation

Asthma ICD-10 Codes

Clinical Scenario

Chief Complaint

Asthma exacerbation

History

6 year old male, established patient.

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

Mother states 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 prednisoine

Family history of asthma

The correct Diagnosis Codes

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.

Renee Dowling is billing and coding consultant with VEI Consulting in Indianapolis, Indiana.