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J45.21
ICD-10-CM
Mild Intermittent Asthma with Exacerbation

Find information on Mild Intermittent Asthma with Exacerbation including clinical documentation, medical coding, ICD-10 codes, and SNOMED CT codes. Learn about diagnosis criteria, treatment guidelines, and management of acute asthma exacerbations for mild intermittent asthma. This resource provides healthcare professionals with essential information for accurate and efficient documentation and coding of Mild Intermittent Asthma with Exacerbation in clinical practice. Explore resources for asthma severity classification, differential diagnosis, and best practices for patient care.

Also known as

Mild Intermittent Asthma with Acute Exacerbation

Diagnosis Snapshot

Key Facts
  • Definition : Asthma symptoms less than twice a week, nighttime awakenings less than twice a month.
  • Clinical Signs : Wheezing, coughing, shortness of breath, chest tightness during exacerbations.
  • Common Settings : Primary care, urgent care, emergency room during severe exacerbations.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC J45.21 Coding
J45.20-J45.21

Mild intermittent asthma

Mild asthma with infrequent symptoms and exacerbations.

J45.90-J45.99

Unspecified asthma

Asthma not further specified, including cases with exacerbations.

J46

Status asthmaticus

Severe, prolonged asthma attack requiring emergency treatment.

Code-Specific Guidance

Decision Tree for

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

Is asthma confirmed?

  • Yes

    Is it currently an exacerbation?

  • No

    Do not code asthma. Review for alternative diagnosis.

Code Comparison

Related Codes Comparison

When to use each related code

Description
Mild intermittent asthma with exacerbation
Mild persistent asthma
Status asthmaticus

Documentation Best Practices

Documentation Checklist
  • Document FEV1/FVC ratio during exacerbation.
  • Symptom frequency: <2 days/week.
  • Nighttime awakenings: <2x/month.
  • Short-acting beta-agonist use: <2 days/week.
  • Exacerbation requiring oral corticosteroids.

Coding and Audit Risks

Common Risks
  • Exacerbation Coding

    Risk of miscoding the exacerbation status, leading to inaccurate severity reflection and reimbursement.

  • Severity Mismatch

    Documentation may not support "mild intermittent" with exacerbation, causing coding conflicts and audit denials.

  • Missing Triggers/Medications

    Lack of documented triggers/medications used during exacerbation impacts accurate coding and care planning.

Mitigation Tips

Best Practices
  • Identify and avoid triggers (ICD-10 J45.20)
  • Proper inhaler technique training (CPT 94664)
  • Asthma action plan creation/review (SNOMED CT 736173001)
  • Medication adherence counseling (RxNorm 726434)
  • Regular peak flow monitoring for CDI accuracy

Clinical Decision Support

Checklist
  • Verify intermittent symptoms <2 days/week
  • Confirm nighttime awakenings <2x/month
  • Check FEV1/FVC >80% predicted
  • Document current exacerbation criteria
  • Assess symptom control before exacerbation

Reimbursement and Quality Metrics

Impact Summary
  • Reimbursement Impact Summary: Mild Intermittent Asthma with Exacerbation ICD-10 J45.21, CPT 99213-99215 (Severity Dependent)
  • Coding Accuracy: Correct E/M coding based on MDM impacts RVU and reimbursement. Avoid unspecified codes.
  • Quality Metrics Impact: Asthma control assessment, medication reconciliation documented impacts quality reporting.
  • Hospital Reporting: Accurate documentation of exacerbation severity affects quality data and resource allocation.

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 J45.21 for exacerbation
  • Document symptom frequency
  • Specify trigger if known
  • Note FEV1/PEF values
  • Check medical necessity guidelines

Documentation Templates

Patient presents with an acute exacerbation of mild intermittent asthma.  The patient reports increased shortness of breath, wheezing, and chest tightness over the past 24 hours.  Symptoms are triggered by recent upper respiratory infection symptoms including rhinorrhea and cough.  Patient denies fever.  Past medical history is significant for mild intermittent asthma, diagnosed two years prior.  Asthma symptoms are typically well-controlled with albuterol as needed, used less than twice per week with no nocturnal symptoms between exacerbations.  Current medications include albuterol MDI as needed.  Physical exam reveals diffuse wheezing bilaterally with prolonged expiratory phase.  Oxygen saturation is 96% on room air.  Peak expiratory flow rate is reduced at 75% of predicted.  Diagnosis of mild intermittent asthma with acute exacerbation is confirmed.  Treatment plan includes albuterol nebulizer treatment administered in office, a short course of oral corticosteroids (prednisone), and continued use of albuterol MDI as needed.  Patient education provided regarding asthma management, trigger avoidance, and proper inhaler technique.  Follow-up scheduled in one week to assess symptom control and adjust treatment plan as necessary.  ICD-10 code J45.20, mild intermittent asthma with acute exacerbation, is assigned.
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