Asthma Documentation Guide
Chronic airway inflammation causing reversible airflow obstruction.
ICD-10 Codes: J45.20, J45.30, J45.40, J45.50
Common Symptoms
- Wheezing
- Shortness of breath
- Chest tightness
- Cough
Key Documentation Elements
- Asthma severity classification
- Control status (well-controlled, not well-controlled, very poorly controlled)
- Controller and rescue medication use
- Trigger identification
- Peak flow or spirometry if available
Documentation Challenges
- Classifying asthma severity
- Documenting control status
- Recording trigger assessment
- Capturing medication step therapy
Billing Considerations
- Severity-specific coding
- Acute vs chronic documentation
- Asthma action plan documentation
Frequently Asked Questions
How is asthma severity coded?
Asthma severity determines the code: mild intermittent (J45.20), mild persistent (J45.30), moderate persistent (J45.40), severe persistent (J45.50). Scribeable selects based on documented symptoms and medication requirements.