Moderate persistent asthma with (acute) exacerbation
ICD-10 J45.41 is a billable code used to indicate a diagnosis of moderate persistent asthma with (acute) exacerbation.
J45.41 refers to moderate persistent asthma with acute exacerbation, a chronic inflammatory disorder of the airways characterized by variable airflow obstruction and hyper-responsiveness. Patients typically present with symptoms such as wheezing, shortness of breath, chest tightness, and coughing, particularly at night or early morning. The anatomy involved includes the bronchial tubes, which become inflamed and narrowed during exacerbations, leading to difficulty in breathing. Disease progression can vary, with some patients experiencing frequent exacerbations requiring urgent care, while others may have well-controlled asthma with infrequent attacks. Diagnostic considerations include a thorough patient history, physical examination, and pulmonary function tests to assess airflow limitation. Peak flow monitoring and allergy testing may also be utilized to identify triggers and assess the severity of asthma. Management often involves a combination of long-term control medications, such as inhaled corticosteroids, and quick-relief medications for acute symptoms. Regular follow-up is essential to adjust treatment plans based on symptom control and exacerbation frequency.
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
J45.41 covers moderate persistent asthma that is currently experiencing an acute exacerbation. This includes patients who have a history of asthma with symptoms occurring more than twice a week but less than daily, and who may require the use of rescue medications more frequently during exacerbations.
J45.41 should be used when a patient with moderate persistent asthma is experiencing an acute exacerbation. It is important to differentiate this from J45.40, which is used for moderate persistent asthma without exacerbation, to ensure appropriate treatment and management.
Documentation for J45.41 should include a detailed account of the patient's asthma history, frequency and severity of exacerbations, treatment plans, response to medications, and any triggers identified. Clinical notes should clearly indicate the acute nature of the exacerbation and the patient's current symptoms.
