JD, a 7-year-old established patient with asthma, presents for an annual wellness visit. JD’s parents are asked to complete a Childhood Asthma Control Test prior to physician evaluation. The test result shows increases in asthma symptoms and interference with moderate activity. (Note: The following example is intended to illustrate documentation and coding and not intended to indicate an exclusive course of treatment or serve as a standard of care.)

Diagnoses are well-child visit, inadequate control of moderate persistent asthma, allergic rhinitis, and encounter for immunization against influenza.

What diagnosis and procedure codes are appropriate for reporting this encounter? (Assume age- and gender- appropriate preventive service was completed and appropriately documented.) See the answer and explanations in this month’s Online Exclusives.

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