Learn about persistent asthma diagnosis, including clinical documentation requirements, ICD-10-CM codes (J45.2, J45.3, J45.4, J45.5), medical coding guidelines, and severity assessment (mild, moderate, severe) for accurate healthcare reporting. Find information on managing persistent asthma, long-term control medications, and best practices for documenting exacerbations and symptom control in electronic health records. Understand the difference between intermittent and persistent asthma for proper diagnosis coding and improved patient care.
Also known as
Asthma
Covers all types of asthma, including persistent.
Mild persistent asthma
Specifies mild persistent asthma severity.
Moderate persistent asthma
Specifies moderate persistent asthma severity.
Severe persistent asthma
Specifies severe persistent asthma severity.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is asthma confirmed?
Yes
Is it persistent?
No
Rule out other diagnoses
When to use each related code
Description |
---|
Persistent asthma: Continual symptoms. |
Intermittent asthma: Occasional symptoms. |
Exercise-induced bronchoconstriction: Asthma with exercise. |
Coding asthma as persistent without documented impairment, airflow limitation, or medication use based on symptoms alone.
Miscoding acute exacerbations requiring hospitalization as persistent asthma instead of status asthmaticus (J46).
Incorrectly coding COPD or other respiratory conditions as persistent asthma without proper diagnostic workup.
Patient presents with persistent asthma, characterized by chronic airway inflammation and reversible airflow obstruction. Symptoms, including wheezing, shortness of breath (dyspnea), chest tightness, and cough, are reported as occurring frequently, often daily, and may interfere with sleep and daily activities. Patient reports a history of recurrent exacerbations requiring oral corticosteroids or emergency room visits within the past year. Pulmonary function testing (PFTs), including FEV1 and FVC measurements, demonstrates evidence of airflow limitation consistent with persistent asthma. Severity is classified as [mild, moderate, or severe] persistent asthma based on symptom frequency, nighttime awakenings, lung function impairment (FEV1 percent predicted), and interference with normal activity. Differential diagnoses considered include chronic obstructive pulmonary disease (COPD), bronchitis, vocal cord dysfunction, and upper airway obstruction. Asthma control is currently deemed [well-controlled, not well-controlled, or very poorly controlled]. Treatment plan includes inhaled corticosteroids (ICS) as controller medication, with the addition of a long-acting beta-agonist (LABA) as needed. Short-acting beta-agonists (SABAs) are prescribed for quick relief of acute symptoms. Patient education provided on asthma triggers, medication adherence, proper inhaler technique, and asthma action plan. Follow-up scheduled to assess treatment response, adjust medications as necessary, and monitor asthma control. ICD-10 code J45.41 (persistent asthma) is assigned. Medical billing codes for services rendered will be documented appropriately.