N91.2 - Amenorrhea, unspecified

Clinical Definition

Asthma is a chronic respiratory condition characterized by inflammation and narrowing of the airways, causing difficulty breathing, wheezing, coughing, and chest tightness.

Documentation Requirements

• Severity Level:

  • Mild intermittent

  • Mild persistent

  • Moderate persistent

  • Severe persistent

• Status:

  • Uncomplicated

  • With acute exacerbation

  • With status asthmaticus

• Type:

  • Allergic

  • Non-allergic

  • Exercise-induced

  • Occupational

• Control Status:

  • Controlled

  • Partially controlled

  • Uncontrolled

Common Synonyms

• Reactive airway disease

• Bronchial asthma

• Wheezing

• "Breathing problems"

• "Tight chest"

Coding Conflicts

• Excludes1:

  • Chronic obstructive asthma with acute exacerbation

  • Detergent asthma

  • Miner's asthma

• Excludes2:

  • Wheezing NOS

  • Acute bronchitis with bronchospasm

Scribing.io Automation

The AI scribe automatically identifies:

• Severity descriptors in the narrative

• Exacerbation status from vital signs and symptoms

• Control status based on medication adjustments

• Distinguishes between asthma types based on triggers mentioned

• Captures frequency of rescue inhaler use

• Documents PFT results when available