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Asthma

Chief Complaint:

8 year old female here for follow up to ER visit 2 days ago for shortness of breath. The patient was discharged with a diagnosis of asthma and albuterol inhaler prescription. Patient is stable on inhaler.

History:

  • Patient has seasonal allergies with rhinorrhea and a history of wheezing during physical exertion. Last episode occurred during PE at school and the patient was taken to the ER for assessment and treatment.
  • Patient has been exposed to second hand cigarette smoke since infancy; father is a pack-a-day smoke
  • The patient has a history of moderately severe episodes of awakening at night approximately 2 times a week requiring the use of an inhaler.

Assessment:

  • Moderate persistent asthma
  • Seasonal Allergic Rhinitis
  • Second hand smoke exposure

Documentation Tips

  • ICD-10 does not include the concept of extrinsic, but does include whether asthma is mild intermittent or persistent or moderate and severe persistent.
  • ICD-10 guidelines now require the use of an additional code to indicate if a patient is exposed to tobacco smoke.

Comparison of Current ICD-9 Code and Illustrative ICD-10 Codes

ICD-9-CM

493.21 Chronic obstructive asthma with status asthmaticus

477.0 Allergic rhinitis due to pollen

ICD-10-CM

J45.41 Moderate persistent asthma with (acute) exacerbation

J30.1 Allergic rhinitis due to pollen

Z77.22 Contact with and (suspected) exposure to environmental tobacco smoke (acute) (chronic)