Avoid Unspecified Codes When a NOS Diagnosis Is Made
Question: A patient presented to our outpatient pulmonology clinic with wheezing, shortness of breath, and chest tightness. The patient attested that the symptoms had been occurring a couple times a week. The pulmonologist performed spirometry, administered a bronchodilator, and then performed the spirometry again. The second test showed significant improvement in lung function after bronchodilator use. The pulmonologist diagnosed the patient with “mild intermittent asthma NOS” and prescribed inhaled corticosteroids. Would we assign J45.909 for this diagnosis? Maine Subscriber Answer: No, you won’t use J45.909 (Unspecified asthma, uncomplicated) for the diagnosis. Instead, you’ll assign J45.20 (Mild intermittent asthma, uncomplicated) for the documented diagnosis. Patients with mild intermittent asthma will experience symptoms two or fewer days each week, aren’t limited in their daily activities, need a rescue inhaler two or fewer days per week, and may be awakened by the asthma at night two or fewer times per month. The unspecified asthma code, J45.909, is applicable if the provider’s documentation does not indicate a certain type of asthma that is covered by another code. In your case, the pulmonologist explicitly documented a mild intermittent asthma not otherwise specified (NOS) diagnosis. This term is also listed as an alternative diagnosis in the ICD-10-CM code book under the main descriptor for J45.20. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
