What Makes Asthma ‘Uncomplicated’?
Question: A 35-year-old patient was referred to the pulmonology clinic due to their wheezing, shortness of breath, and chest tightness. They stated they experienced the symptoms three to four times in the last month. The pulmonologist performed spirometry before and after administering albuterol. The results showed improved lung function after the short-acting beta-agonist (SABA). The pulmonologist diagnosed the patient with uncomplicated mild persistent asthma. How do I report the diagnosis? Texas Subscriber Answer: Use J45.30 (Mild persistent asthma, uncomplicated) to report the patient’s diagnosis. This type of asthma can cause symptoms such as chest tightness, wheezing, and shortness of breath, which occur regularly. However, this specific form of asthma doesn’t have additional complications associated with it, which means it’s uncomplicated. Also, you should double-check the patient record to see if they have any exposure to tobacco smoke, have a dependence on tobacco, or use tobacco, as these factors will require additional codes on your claim. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
