Moderate persistent asthma, uncomplicated
ICD-10 J45.40 is a billable code used to indicate a diagnosis of moderate persistent asthma, uncomplicated.
Moderate persistent asthma is characterized by daily symptoms that require the use of a short-acting beta-agonist for relief, occurring more than twice a week but not daily. Patients may experience nighttime symptoms more than once a month, and lung function tests typically show a FEV1 (Forced Expiratory Volume in one second) between 60% and 80% of predicted values. The respiratory system, particularly the bronchi and bronchioles, is primarily affected, leading to inflammation, increased mucus production, and bronchoconstriction. Disease progression can vary, with some patients experiencing exacerbations that may require systemic corticosteroids or hospitalization. Diagnostic considerations include a thorough patient history, physical examination, and spirometry to assess lung function. Additionally, identifying triggers such as allergens, irritants, and respiratory infections is crucial for effective management.
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
J45.40 covers moderate persistent asthma, which includes patients experiencing daily symptoms requiring rescue inhalers, with nighttime symptoms occurring more than once a month. It does not include patients with mild or severe persistent asthma.
J45.40 should be used when a patient exhibits moderate persistent asthma symptoms as defined by the frequency of symptoms and lung function tests. It is important to differentiate from J45.30 and J45.50 based on symptom severity and treatment needs.
Documentation should include a detailed history of asthma symptoms, frequency of exacerbations, response to treatment, and results from spirometry tests. This information is crucial for justifying the use of J45.40.
