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Chief Complaint:

8 year old female here for follow up to ER visit 2 days ago for shortness of breath. The patient was discharged with a diagnosis of asthma and albuterol inhaler prescription. Patient is stable on inhaler.


  • Patient has seasonal allergies with rhinorrhea and a history of wheezing during physical exertion. Last episode occurred during PE at school and the patient was taken to the ER for assessment and treatment.
  • Patient has been exposed to second hand cigarette smoke since infancy; father is a pack-a-day smoke
  • The patient has a history of moderately severe episodes of awakening at night approximately 2 times a week requiring the use of an inhaler.


  • Moderate persistent asthma
  • Seasonal Allergic Rhinitis
  • Second hand smoke exposure

Documentation Tips

  • ICD-10 does not include the concept of extrinsic, but does include whether asthma is mild intermittent or persistent or moderate and severe persistent.
  • ICD-10 guidelines now require the use of an additional code to indicate if a patient is exposed to tobacco smoke.

Comparison of Current ICD-9 Code and Illustrative ICD-10 Codes


493.21 Chronic obstructive asthma with status asthmaticus

477.0 Allergic rhinitis due to pollen


J45.41 Moderate persistent asthma with (acute) exacerbation

J30.1 Allergic rhinitis due to pollen

Z77.22 Contact with and (suspected) exposure to environmental tobacco smoke (acute) (chronic)