L63.9 - Alopecia areata, unspecified

Clinical Definition

Asthma is a chronic respiratory condition characterized by inflammation and narrowing of the airways, leading to wheezing, shortness of breath, chest tightness, and coughing.

Documentation Requirements

• Must specify severity:

  • Mild intermittent

  • Mild persistent

  • Moderate persistent

  • Severe persistent

• Document presence of:

  • Acute exacerbation (if applicable)

  • Status asthmaticus (if applicable)

• Specify type:

  • Allergic

  • Non-allergic

  • Mixed

• Note presence or absence of complications

• Document smoking status/exposure

• Indicate level of control:

  • Well controlled

  • Partially controlled

  • Poorly controlled

Common Synonyms

• Reactive airway disease

• Bronchial asthma

• Wheezing attacks

• Breathing problems

• Bronchospasm

Coding Conflicts

Excludes1:

• Chronic obstructive asthma with acute exacerbation (J44.1)

• Detergent asthma (J69.8)

• Miner's asthma (J60)

Excludes2:

• Wheezing NOS (R06.2)

• Eosinophilic asthma (J82)

Scribing.io Automation

The AI scribe automatically identifies and captures:

• Key asthma descriptors in patient history

• Severity indicators from physical exam findings

• Trigger factors mentioned during visit

• Treatment response details

• Pulmonary function test results

• Peak flow measurements

• Control assessment parameters

These elements are automatically organized into appropriate sections of the note while maintaining medical necessity documentation.