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Z87.01
ICD-10-CM
History of Asthma

Find comprehensive information on documenting a history of asthma in medical records. This resource covers clinical indicators, diagnostic criteria, ICD-10 codes (J45), SNOMED CT concepts, and best practices for accurate and complete healthcare documentation related to asthma history. Learn about proper terminology for past asthma diagnoses, controlled asthma, childhood asthma, adult-onset asthma, and intermittent asthma for improved clinical communication and medical coding accuracy. Explore resources for healthcare professionals, including physicians, nurses, and medical coders.

Also known as

Asthma history
Past asthma
Resolved asthma

Related ICD-10 Code Ranges

Complete code families applicable to AAPC Z87.01 Coding
J45-J46

Asthma and status asthmaticus

Covers all types of asthma and acute exacerbations.

Z87.0

Personal history of asthma

Specifically indicates a past history of asthma.

J40-J47

Chronic lower respiratory diseases

Includes asthma along with other chronic respiratory conditions.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is asthma currently active?

  • Yes

    Do NOT code history of asthma. Code the active asthma with appropriate severity (e.g., J45.21, J45.32).

  • No

    Is asthma completely resolved?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Asthma, unspecified
Acute exacerbation of asthma
Exercise-induced asthma

Documentation Best Practices

Documentation Checklist
  • Asthma diagnosis date, ICD-10 G45.x
  • Symptom onset, frequency, severity
  • Triggers: allergens, irritants, exercise
  • Medications, response to treatment
  • Lung function tests: FEV1, FVC

Coding and Audit Risks

Common Risks
  • Unspecified Asthma Type

    Coding unspecified asthma (J45.909) when a more specific type is documented in the chart, leading to inaccurate severity reflection and reimbursement.

  • Status Asthmaticus Overlook

    Missing documentation of status asthmaticus (J46) when clinical indicators are present, resulting in undercoding and missed severity capture.

  • Exacerbation vs. History

    Incorrectly coding acute exacerbation (J45.911) for patients with a history of asthma, when no current exacerbation is present, impacting data accuracy.

Mitigation Tips

Best Practices
  • Document asthma onset, triggers, severity, control level for accurate ICD-10 coding (J45.xx).
  • Use specific terminology: 'controlled', 'partly controlled', 'uncontrolled' for compliant CDI.
  • Record all medications, including preventers and relievers, for proper HCC coding and risk adjustment.
  • Regularly review patient history and update asthma documentation for ongoing care management.
  • Clearly distinguish between asthma exacerbation (J45.901) and status asthmaticus (J46) in records.

Clinical Decision Support

Checklist
  • Verify wheezing, shortness of breath, cough, chest tightness documented.
  • Confirm episodic symptoms and triggers (allergens, exercise, etc.) noted.
  • Check for prior asthma diagnosis, treatment, or medication history.
  • Review spirometry or peak flow results if available for airflow limitation.
  • Ensure appropriate ICD-10 code (e.g., J45) for asthma severity documented.

Reimbursement and Quality Metrics

Impact Summary
  • Asthma Diagnosis Reimbursement: Accurate coding (ICD-10 J45) maximizes payments, avoids denials. Proper documentation supports medical necessity.
  • Quality Metrics Impact: History of asthma (J45) influences HEDIS measures for respiratory care management, impacting hospital quality scores.
  • Coding Accuracy for Asthma: Correct J45 subcodes (e.g., J45.20, J45.909) ensure appropriate severity reflection for accurate reimbursement.
  • Hospital Reporting: Accurate asthma diagnosis data (J45) is crucial for public health reporting, resource allocation, and quality improvement initiatives.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes for . Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • Code J45.xx for asthma type
  • Document severity & triggers
  • Specify if intermittent/persistent
  • Note control status (well/poor)
  • Check for exacerbations (J45.909)

Documentation Templates

Patient presents with a history of asthma, characterized by recurrent episodes of wheezing, shortness of breath, chest tightness, and cough.  Onset of symptoms initially occurred during childhood.  Patient reports intermittent exacerbations triggered by various factors including allergens such as dust mites, pet dander, and pollen, as well as environmental irritants like smoke and strong odors.  Viral respiratory infections also frequently precipitate asthma attacks.  Patient denies any current symptoms.  Pulmonary function testing performed previously demonstrated reversible airway obstruction, confirming the diagnosis of asthma.  Current medications include an albuterol inhaler as needed for acute symptoms.  The patient understands the importance of asthma management, including trigger avoidance and proper inhaler technique.  Assessment includes chronic asthma, well-controlled.  Plan includes continuing current medication regimen, patient education regarding asthma triggers and management, and follow-up for reassessment of asthma control and medication efficacy.  Differential diagnoses considered included bronchitis, allergic rhinitis, and chronic obstructive pulmonary disease.  ICD-10 code J45.90, Unspecified asthma, is assigned.  Keywords: asthma, wheezing, shortness of breath, dyspnea, cough, airway obstruction, bronchospasm, inhaler, albuterol, pulmonary function test, spirometry, allergens, triggers, respiratory infection, chronic disease management, ICD-10, J45.90, medical coding, billing, electronic health records, EHR, healthcare documentation.
History of Asthma - AI-Powered ICD-10 Documentation