A Moderate-Complexity Visit on Paper: Assigning ICD-10-CM Codes and an Office Visit Level to an Asthma Follow-Up Note, and Why the Spirometry Cannot Be Counted Twice
[Student Name]
University of Phoenix
NRP/531: Advanced Health Assessment I
Week 2 Assignment
[Instructor Name]
[Date]
The patient and note are composites written for a model paper. Coding rules change each year; students should use the current code set and guidelines.
The assignment gives an established-patient visit note for Mr. L., a 34-year-old warehouse forklift operator, and asks for the diagnosis codes and office visit level it supports. This paper summarizes the note, codes it and explains each choice.
The Note, Summarized
Subjective: Mr. L. has moderate persistent asthma treated with a low-dose inhaled corticosteroid-formoterol inhaler. Over six weeks he has used his reliever about four days a week and woken at night twice, with more symptoms when dust rises in the warehouse. He had no emergency visits or oral steroids. He also reports spring sneezing and nasal congestion and smokes about half a pack a day.
Objective: vital signs normal, oxygen saturation 97%. Scattered expiratory wheezes, no distress. Nasal mucosa pale and swollen. In-office spirometry before and after bronchodilator: FEV1 71% of predicted, improving 14% after bronchodilator.
Assessment: moderate persistent asthma, not well controlled, no exacerbation; seasonal allergic rhinitis; nicotine dependence, cigarettes.
Plan: increase to the medium-dose step of the same inhaler for maintenance and relief; start an intranasal corticosteroid; counsel on smoking cessation for four minutes and prescribe nicotine patches; workplace dust mask; follow-up in four weeks.
Diagnosis Coding
The ICD-10-CM guidelines direct coders to assign codes to the highest degree of specificity supported by the documentation (Centers for Medicare & Medicaid Services & National Center for Health Statistics, 2024).
Asthma: the note documents moderate persistent asthma and states no exacerbation, so the code is J45.40, moderate persistent asthma, uncomplicated. If the note had documented an acute exacerbation, J45.41 would apply; not well controlled is not the same as an exacerbation, and coding one from the other would overstate the visit. The asthma classification in the note follows the national guideline's severity and control categories (Cloutier et al., 2020).
Allergic rhinitis: the note documents seasonal symptoms without naming the allergen, so J30.2, other seasonal allergic rhinitis, fits. If pollen were documented as the cause, J30.1 would apply.
Tobacco: the note documents nicotine dependence due to cigarettes without complications, F17.210. The guidelines distinguish dependence from tobacco use, Z72.0; the clinician's diagnosis of dependence determines the code.
A code can be no more specific than the sentence that supports it; every digit added must be found in the note.
Procedure Coding
Spirometry with pre- and post-bronchodilator testing is billed separately as a procedure. Because it is billed, its interpretation cannot also be counted as data toward the visit's medical decision making (American Medical Association, 2023). Smoking cessation counseling of three to ten minutes may be billed with its own code when documented with time, as it is here.
The Visit Level by Medical Decision Making
Under current office visit guidelines, the level may be chosen by medical decision making, which has three elements: how many problems were addressed and how complex they are, what data were reviewed or ordered and how much risk the management choices carry. Two of the three elements must meet or exceed a level (American Medical Association, 2023).
Problems: asthma that is not well controlled is a chronic illness with progression, which is moderate. Allergic rhinitis and nicotine dependence add to the picture. The problem element is moderate.
Data: with spirometry excluded because it is billed separately, the note documents no other tests reviewed or ordered and no independent historian. The data element is minimal or low.
Risk: increasing the inhaled steroid dose, starting an intranasal steroid and prescribing nicotine patches are prescription drug management, which is moderate risk.
With problems moderate and risk moderate, medical decision making is moderate, supporting 99214, an established-patient office visit of moderate complexity.
Checking Against Time
Time is an alternative. The note records 32 minutes of total clinician time on the date of service, including review, examination, counseling and documentation, excluding the separately billed spirometry and cessation counseling. That time also supports 99214. Either method may be used; the clinician should choose the one the documentation supports best and state it.
What Would Change the Level
If the note had omitted the dose change and prescriptions, risk would drop to low and the level to 99213. If an exacerbation requiring systemic steroids had been documented, problems might rise, but risk would remain moderate unless decision making about hospitalization were documented.
Common Errors on This Worksheet
Students often make four errors on this kind of worksheet. The first is coding asthma with exacerbation because the patient has symptoms; the note must document an exacerbation for J45.41. The second is coding unspecified asthma, J45.909, when the note documents severity; unspecified codes are for notes that lack detail, not for convenience. The third is counting the billed spirometry as data and raising the level. The fourth is ignoring the tobacco code, which both reflects the work of counseling and supports the separately billed cessation service.
Why Coding Accuracy Matters Beyond Payment
Diagnosis codes follow the patient. They populate problem lists, feed quality measures such as asthma control rates and inform research using claims data. An asthma visit coded as unspecified hides the severity from quality programs, and an exacerbation coded without documentation could affect the patient's insurance records. Accurate coding is a clinical responsibility as well as a financial one.
How a Compliance Review Would Read This Note
A payer's reviewer would look for the same elements scored above: a clear statement of each problem and its status, evidence that each was addressed, the prescription changes and the time statement. A note that lists diagnoses without showing they were addressed would not support the problem element even if the codes were correct. Mr. L.'s note addresses each problem with an assessment and a plan, which is why it holds up.
Documentation Lessons
Three lessons follow. Write the asthma severity and control status in the assessment in words that match coding categories. Record prescription decisions explicitly, since they drive risk. State time when time will be used, and keep separately billed services separate.
A Note on Modifiers
When a separately billable procedure such as spirometry is performed on the same day as a significant, separately identifiable office visit, payers may require a modifier on the visit code to show that the visit was more than the work of the procedure. The note supports this, because the visit addressed three problems and changed treatment beyond interpreting the test.
If the Visit Were a New Patient
New-patient codes use the same medical decision making framework but different code numbers and time thresholds. Because Mr. L. has been seen in the practice within three years, established-patient codes apply.
Conclusion
The note supports J45.40, J30.2 and F17.210, separately billed spirometry and cessation counseling and an office visit of 99214 by moderate medical decision making, confirmed by time. Coding followed the note rather than the clinician's intention, and the most common error, counting billed spirometry as data, was avoided.
References
American Medical Association. (2023). CPT evaluation and management (E/M) services guidelines. https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf
Centers for Medicare & Medicaid Services & National Center for Health Statistics. (2024). ICD-10-CM official guidelines for coding and reporting FY 2025. https://www.cms.gov/files/document/fy-2025-icd-10-cm-coding-guidelines.pdf
Cloutier, M. M., Baptist, A. P., Blake, K. V., Brooks, E. G., Bryant-Stephens, T., DiMango, E., Dixon, A. E., Elward, K. S., Hartert, T., Krishnan, J. A., Lemanske, R. F., Jr., Ouellette, D. R., Pace, W. D., Schatz, M., Skolnik, N. S., Stout, J. W., Teach, S. J., Umscheid, C. A., & Walsh, C. G. (2020). 2020 focused updates to the asthma management guidelines: A report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. Journal of Allergy and Clinical Immunology, 146(6), 1217-1270. https://doi.org/10.1016/j.jaci.2020.10.003
How this NRP 531 Week 2 example is structured
The NRP/531 Week 2 work usually asks students to review a visit note and determine the diagnosis codes and visit level it supports. This paper reads the note first, codes each problem with its supporting documentation, scores the three elements of medical decision making and checks the result against time, showing where documentation decides the answer. Students search this week as NRP 531 Week 2, NRP531 Wk 2 or NRP/531 Wk 2; all three are the same assignment.
NRP/531 Week 2 questions, answered
What does NRP/531 Week 2 usually ask for?
Many sections introduce coding and billing with a worksheet in which students review a SOAP note and assign ICD-10-CM diagnosis codes and an evaluation and management level.
How is an office visit level chosen?
By medical decision making, based on the number and complexity of problems, the data reviewed and the risk of management, with two of three elements required, or by the clinician's total time on the date of the visit.
Can in-office spirometry count toward data in decision making?
If the spirometry is billed separately, its interpretation is not also counted as data for the visit level, because that would count the same work twice.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official University of Phoenix document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.