Internal Medicine Coding Alert

Published on Mon Sep 07, 2009 PDF

Question: A patient presents with mild, intermittent asthma. What ICD-9 code should we use?

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Answer: Unless the internist's documentation offers more details, you should report 493.90 (Asthma, unspecified; unspecified). Most coding experts consider mild, intermittent asthma unspecified, as one cannot discern the etiology or the duration of the disease from the diagnosis alone.

You may want to check with the internist to get additional information and documentation as to the most accurate diagnosis. Was the patient having acute sign/symptoms of mild asthma or is the patient just expressing her history, meaning that from time to time she has mild symptoms? If a patient has intermittent asthma that responds to rescue inhaler use and is not exhibiting any signs/symptoms at the time of evaluation, you should use the unspecified code.

-- Answers to You Be the Coder and Reader Questions were reviewed by Bruce Rappoport, MD, CPC, CHCC, a board-certified internist and medical director of Broward Health's Best Choice Plus and Total Claims Administration in Fort Lauderdale, Fla.