Moderate persistent asthma
ICD-10 J45.4 is a used to indicate a diagnosis of moderate persistent asthma.
Moderate persistent asthma is characterized by daily symptoms that require the use of a rescue inhaler on a daily basis and may interfere with normal activities. Patients typically experience nighttime symptoms more than once a week but not nightly. The condition involves inflammation and narrowing of the airways, leading to difficulty in breathing, wheezing, chest tightness, and coughing. The anatomy involved includes the bronchi and bronchioles, which are the air passages in the lungs. Disease progression can vary; while some patients may experience stable periods, others may have exacerbations that require increased medication or hospitalization. Diagnostic considerations include a thorough patient history, physical examination, and spirometry tests to assess lung function. The presence of triggers such as allergens, irritants, and respiratory infections should also be evaluated to manage the condition effectively.
Standard ICD-10-CM documentation requirements apply
Various clinical presentations within this specialty area
Follow specialty-specific billing guidelines
Standard ICD-10-CM documentation requirements apply
Various clinical presentations within this specialty area
Follow specialty-specific billing guidelines
J45.4 covers moderate persistent asthma, which includes patients experiencing daily symptoms that require medication for control and may have nighttime symptoms more than once a week. It does not include severe asthma or mild persistent asthma, which are classified under different codes.
J45.4 should be used when a patient exhibits moderate persistent asthma symptoms, characterized by daily use of rescue inhalers and frequent nighttime symptoms. It is important to differentiate it from mild persistent asthma (J45.2) and severe asthma (J45.5) based on the frequency and severity of symptoms.
Documentation for J45.4 should include a detailed history of asthma symptoms, frequency of exacerbations, medication usage, and results from lung function tests such as spirometry. Additionally, any identified triggers and the patient's response to treatment should be documented.
