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 and status asthmaticus
Covers all types of asthma and acute exacerbations.
Personal history of asthma
Specifically indicates a past history of asthma.
Chronic lower respiratory diseases
Includes asthma along with other chronic respiratory conditions.
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?
When to use each related code
Description |
---|
Asthma, unspecified |
Acute exacerbation of asthma |
Exercise-induced asthma |
Coding unspecified asthma (J45.909) when a more specific type is documented in the chart, leading to inaccurate severity reflection and reimbursement.
Missing documentation of status asthmaticus (J46) when clinical indicators are present, resulting in undercoding and missed severity capture.
Incorrectly coding acute exacerbation (J45.911) for patients with a history of asthma, when no current exacerbation is present, impacting data accuracy.
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.