The child in question presented for a well-child visit and was found to have inadequate control of a known chronic condition, asthma. Based on International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) guidelines for reporting routine child health examinations, this is reported as an encounter with abnormal findings because the chronic condition was not adequately controlled. ICD-10-CM codes for the encounter are

Code J45.41 is reported when asthma is noted as exacerbated (ie, worsening or becoming more symptomatic). Although code J45.41 is often reported for acute exacerbations in which the patient presents with asthma symptoms at the time of encounter, the term acute is a supplementary term and not required for assignment of code J45.41. Allergic rhinitis is not separately reported, as the ICD-10-CM index directs to report the appropriate asthma code when allergic rhinitis is associated with asthma.

The patient is noted to be an...

You do not currently have access to this content.