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