Moderate persistent asthma with (acute) exacerbation

This code signifies a patient diagnosed with moderate persistent asthma who is currently experiencing an acute worsening of their respiratory symptoms. Moderate persistent asthma is characterized by daily symptoms, nighttime awakenings more than once a week but not nightly, and some limitation in normal activity. The "with exacerbation" indicates a temporary but significant increase in the severity of these symptoms, often requiring immediate medical intervention.

Use this code when documentation clearly states a diagnosis of moderate persistent asthma and explicitly mentions an acute exacerbation or flare-up. This typically applies to patients presenting to an emergency department, urgent care, or physician's office for treatment of their worsening asthma symptoms. Supporting documentation should include details of symptom severity, frequency, and the acute nature of the exacerbation.

• Ensure the documentation specifically states "moderate persistent" and "with exacerbation"; avoid assuming severity or exacerbation based on treatment alone.
• Do not use this code for routine follow-up of stable moderate persistent asthma; instead, use J45.40.
• Always sequence this code as the primary diagnosis when the exacerbation is the reason for the encounter.