ICD-10 Coding for Moderate Persistent Asthma Without Complication(J45.40)
Complete ICD-10-CM coding and documentation guide for Moderate Persistent Asthma Without Complication. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Moderate Persistent Asthma Without Complication
J45-J46Primary Range
Asthma and status asthmaticus
This range includes all asthma-related conditions, with J45.40 specifically for moderate persistent asthma without complications.
Key Information: ICD-10 code for moderate persistent asthma
Essential facts and insights about Moderate Persistent Asthma Without Complication
Primary ICD-10-CM Code for moderate persistent asthma without complication
Decision Criteria
clinical Criteria
- Presence of daily asthma symptoms and FEV1 between 60-80%
documentation Criteria
- Explicit documentation of 'moderate persistent asthma, uncomplicated'
Applicable To
- Moderate persistent asthma without acute exacerbation
- Moderate persistent asthma without status asthmaticus
Clinical Validation Requirements
- Daily symptoms such as wheezing or shortness of breath
- Nighttime awakenings ≥1x/week but < nightly
- Beta-agonist use ≥2x/day but not hourly
- FEV1 60-80% predicted
Code-Specific Risks
- Risk of using unspecified codes when specific severity is documented
- Confusing uncomplicated with exacerbation codes
Coding Notes
- Ensure documentation specifies 'moderate persistent asthma, uncomplicated' to avoid coding errors.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Moderate Persistent Asthma Without Complication to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code J45.40.
Impact
Clinical: May lead to inappropriate treatment plans., Regulatory: Non-compliance with coding standards., Financial: Potential for reduced reimbursement.
Mitigation Strategy
Always document asthma severity, Use templates to ensure completeness
Impact
Reimbursement: May lead to lower reimbursement rates., Compliance: Non-compliance with coding guidelines., Data Quality: Decreases accuracy of patient records.
Mitigation Strategy
Use J45.40 when moderate persistent asthma is specified.
Impact
Inadequate documentation of severity can lead to audit issues.
Mitigation Strategy
Use standardized templates and ensure thorough documentation.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Moderate Persistent Asthma Without Complication, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Moderate Persistent Asthma Without Complication
Use these documentation templates to ensure complete and accurate documentation for Moderate Persistent Asthma Without Complication. These templates include all required elements for proper coding and billing.
Routine asthma follow-up
Specialty: PulmonologyRequired Elements
- HPI: Daily symptoms, nighttime awakenings
- PE: Lung exam findings
- Testing: Spirometry results
- A/P: Diagnosis and treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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