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Remember to include a 5^th character when coding an asthma diagnosis.

With roughly 4.9 million children under the age of 18 suffering from asthma in the United States alone, your pediatric office most likely deals with cases regularly. Asthma can best be described as a chronic condition that affects the airways in the lungs. It causes inflammation and narrowing of the bronchial tubes, which leads to increased sensitivity to various triggers.

Continue reading to learn more about diagnosing and coding asthma-related claims in your pediatric practice.

Be Familiar With Signs and Symptoms

According to Karen Perry, CPC, CPB, CPC-I, during her HEALTHCON Regional 2025 presentation, “Let’s Have Some Fun with Pediatric Coding,” there are ongoing updates for the management and prevention of asthma in children ages 5 years and younger using these three criteria:

• Recurrent wheezing
• Timely response to treatment
• An absence of other causes for the asthma

When patients are exposed to their asthma triggers, the airways can become inflamed and produce excess mucus, which in severe cases can lead to an asthma attack. Symptoms of an asthma attack can include shortness of breath, coughing, wheezing, and chest tightness. The severity and frequency of asthma symptoms can vary widely from person to person.

Things like animal dander, secondhand smoke exposure, and pollen are some of the most common triggers.

Here Are the Biomarkers to Look For

Perry mentioned recent highlights in discussions related to type 2 biomarkers for individuals suffering from asthma. Biomarkers help providers identify the type of asthma a patient has and guides them toward the correct form of treatment. These biomarkers include:

• Eosinophils: These are a type of white blood cell that can increase in response to inflammation or infection. High levels of eosinophils in the blood or sputum can be a sign of asthma.
• Fractional exhaled nitric oxide (FeNO): This is a type of gas that is produced by the lungs and can be measured in the breath. High levels of FeNO can indicate inflammation in the lungs and may be a sign of asthma. 
• Immunoglobulin E (IgE): This is a type of antibody that is produced by the immune system in response to allergens. High levels of IgE can indicate an allergic response and may be associated with asthma.
• Spirometry: This is a test that measures how much air you can breathe in and out and how quickly you can do it. It can help diagnose asthma and monitor its severity.

Know Options for Biological Therapies via Injections

Treatment options aren’t limited to inhalers anymore. Updated treatment options include biological therapies in the form of injections that target inflammatory pathways. “Not every approach is going to work the same for every patient. There might be one treatment that works great for one child, but might not work on another. It depends on the circumstances,” said Perry.

Some patient’s symptoms are so severe the practitioner may decide to combine biologic injections with an inhaler. “There are also other inhalers and combinations which are low-dose inhalers combined with long-acting bronchodilators,” Perry said.

According to Perry, there are five main biologicals currently approved by the Food and Drug Administration (FDA) for severe asthma:

• Xolair is approved for patients ages 6 and up. This medication binds to the molecule responsible for triggering allergic reactions. You will code this using J2357 (Injection, omalizumab, 5 mg).
• Nucala is used in eosinophilic asthma and acts by blocking the production of eosinophils and their activation. You will code this using J2182 (Injection, mepolizumab, 1 mg).
• Fasenra targets a type of white blood cell contributing to the inflammation in asthma. This is given every four to eight weeks as directed. You will code this using J0517 (Injection, benralizumab, 1 mg).
• Tezspire works by blocking the action of a molecule that plays a key role in asthma inflammation. This is administered every four weeks. You will code this using J2356 (Injection, Tezepelumab-ekko, 1 mg).
• Dupixent inhibits the action of two key molecules that are also involved in asthma inflammation. This is administered every two to four weeks as indicated. You will code this using J9228 (Injection, ipilimumab,1 mg).

“Biologicals are recommended for uncontrolled asthma, meaning not controlled by inhaled corticosteroids or long-acting bronchodilator medicine,” she said.  Perry stressed the importance of discussing all treatment options in detail with the patient and their parent (if appropriate), to allow them to make an informed decision.

Note: To code for the supply of inhalers, look to codes J7601-J7685 in the HCPCS Level II code book.

Ace Dx Coding for Asthma

Asthma has four different states of severity — intermittent, mild persistent, moderate persistent, and severe persistent — that correspond with the first four code subgroups in the J45.- group and the typical other and unspecified category:

• J45.2- (Mild intermittent asthma)
• J45.3- (Mild persistent asthma)
• J45.4- (Moderate persistent asthma)
• J45.5- (Severe persistent asthma)
• J45.9- (Other and unspecified asthma)

Most of the codes in this group require that 5th character to communicate the patient’s state at the time of the encounter.

It’s typical for an asthma patient to have concurrent health issues. These additional conditions can make asthma management more complex and potentially affect the disease’s severity and control. Therefore, it’s crucial to carefully consider all Excludes2 notes, which suggest the simultaneous existence of two or more conditions. Keep in mind that if the provider has documented these conditions, you can report them together, but they must be reported in the correct sequence on the claim.

Let’s review this example:

A patient with chronic asthma comes into your pediatric office, and Dr. Smith diagnoses them with a cold but also prescribes a steroid inhaler to address the asthmatic cough that’s been worsened by the cold. You will need to report both conditions. In this case, you’ll need to report the cold first and the asthma second.

The chronic asthma in this case impacts treatment like any comorbid condition. Therefore, in this case, you’d report J00 (Acute nasopharyngitis [common cold]), then list J45.901 (Unspecified asthma with (acute) exacerbation) as the second code.

The reason you would list the asthma second in this case is because the patient’s primary reason for the visit was the cold, not the asthma. The asthma is a chronic condition that the patient already has, but the acute condition (the cold) is what prompted the visit and therefore you should list it first. List the asthma listed second because it is a comorbid condition that is affecting the treatment of the primary condition.

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC