• Asthma resolved - go to this
• Exclusion codes - go to this
• Asthma 8.1 Rationale - go to this

Patients aged eight and over diagnosed as having asthma from 1 April 2006

(One of these codes added 3 months before diagnosis, or after)

Spirometry codes for Asthma

33G1. Spirometry reversibility positive

33H1. Positive reversibility test to salbutamol

33I1. Positive reversibility test to ipratropium bromide

33J1. Positive reversibility test to a combination of salbutamol and ipratropium bromide

33K1. Positive reversibility test to corticosteroids

663J. Airways obstruction reversible

8HRC. Referral for spirometry
745D4 Post bronchodilator spirometry

PEFR codes

339A. Peak flow rate before bronchodilation

339B. Peak flow rate after bronchodilation

339c. Peak expiratory flow rate pre steroids

339d. Peak expiratory flow rate post steroids

339g. Serial peak expiratory flow rate

339n. Serial peak expiratory flow rate abnormal

66YX. Peak expiratory flow rate monitoring

66YY. Peak expiratory flow rate monitoring using diary
66Yc. Number of consecutive days at less than 80% peak expiratory flow rate
33950 Diurnal variation of peak expiratory flow rate

Spirometry Exception Codes

Asthma Diagnosis Codes

H33.. Asthma

H330. Extrinsic (atopic) asthma

H3300 Extrinsic asthma without status asthmaticus

H3301 Extrinsic asthma with status asthmaticus

H330z Extrinsic asthma NOS

H331. Intrinsic asthma

H3310 Intrinsic asthma without status asthmaticus

H3311 Intrinsic asthma with status asthmaticus

H331z Intrinsic asthma NOS

H332. Mixed asthma
H333. Acute exacerbation of asthma (v28)

H334. Brittle asthma

H335. Chronic asthma with fixed airflow obstruction
H33z. Asthma unspecified

H33z0 Status asthmaticus NOS
H33z1 Asthma attack

H33z2 Late-onset asthma

H33zz Asthma NOS

H3120 Chronic asthmatic bronchitis

173A. Exercise induced asthma (v27.1)

 

Asthma Resolved (After diagnosis)

21262 Asthma resolved

212G. Asthma resolved

Exclusion codes (Every 12 months)

9hA.. Exception reporting: asthma quality indicators

9hA1. Excepted from asthma quality indicators: Patient unsuitable

9hA2. Excepted from asthma quality indicators: Informed dissent

9OJ2. Refuses asthma monitoring

Asthma 002.1 Rational

There is no single infallible test to confirm a diagnosis of asthma. On the basis of the clinical history and examination it will be possible to decide if the probability of asthma is high, intermediate or low and the aim of investigations is to demonstrate objectively the presence of variability in order to support or reject the diagnosis. There are Read codes for ‘suspected asthma’ and ‘suspected respiratory condition’ which may be used whilst investigations are undertaken and the diagnosis confirmed.

Further information about the diagnosis of asthma is provided in the BTS-SIGN asthma guideline. It is crucial that diagnostic spirometry is performed to published quality standards.

Asthma history

The diagnosis of asthma is suspected when a patient presents a history of variable wheeze, chest tightness, shortness of breath or cough, commonly triggered by viral infections and/or allergy and/or exercise. A personal or family history of atopy (including positive skin prick testing) increases the probability of asthma.

Practices may wish to confirm a diagnosis of asthma for those patients who were diagnosed with asthma in previous QOF years before they were eight years of age. Once the patient turns eight it is acceptable to re-examine the diagnosis using tests of variability or reversibility. In those patients who are not receiving long-term antiinflammatory therapy they should be treated as a new presenting case and the diagnosis re-evaluated.

If asthma is probable

In symptomatic patients airway obstruction may be demonstrated by spirometry (FEV1/FVC ratio <0.7) and (if available) nitric oxide can be used to measure airway inflammation.

Variability of symptoms and/or lung function may be demonstrated in a reversibility test or may occur spontaneously over time in response to triggers or to treatment; demonstration of variability supports the diagnosis of asthma and may be conveniently achieved in primary care in a number of ways:

• Spirometry may be used to demonstrate reversibility in symptomatic patients with demonstrated airflow obstruction. A bronchodilator reversibility test can be performed with inhaled or nebulised short acting beta agonist and if the obstruction reverses then asthma is confirmed. Significant reversibility is a change in FEV1 >12 per cent and 200 ml (the absolute change is scaled down according to predicted FEV1 in children). Increases of >400 mls are strongly suggestive of asthma. Lower levels of bronchodilator reversibility may be demonstrated in some patients with COPD Normal spirometry, however, does not exclude asthma; indeed the variable nature of asthma means that many of the milder patients seen in primary care will be asymptomatic at the time of the lung function test and will have completely normal lung function with no reversibility at the time of testing.
• Variability of PEF. This may be demonstrated by monitoring diurnal, or day to day variation (recorded twice a day for two weeks using the same peak flow meter) and/or demonstrating an increase after therapy (15 minutes after short-acting bronchodilator, after six weeks of inhaled steroids, or up to two weeks after oral steroid treatment) and/or after exposure to triggers (such as exercise, laughter, or allergens). Significant variability is a change of 20 per cent and >60 l/min (the absolute change is scaled down in children to 20 per cent of predicted PEF). PEF are effort dependent and patients need to be taught the correct technique.
• Variability in objective measures of asthma symptom scores (e.g. RCP questions, ACQ, ACT questionnaire, or GINA Control Tool) Symptom scores may be particularly useful in patients unable to undertake accurate serial measures of lung function and to aid clinical interpretation of lung function (e.g. normal lung function in a symptomatic patient might suggest an alternative cause for the symptoms).

A trial of treatment, with repeated lung function measurements and/or symptoms scores over time will demonstrate objective improvement of symptoms and lung function in people with asthma, thereby confirming the diagnosis. In children it is particularly important to reduce and stop treatment to exclude spontaneous improvement.

If the probability of asthma is intermediate

Spirometry is the key investigation for distinguishing obstructive and restrictive respiratory conditions and will determine subsequent investigations.More specialist assessment may be required in those in whom the diagnosis is still unclear, which may include assessment of airway inflammation (e.g. nitric oxide measurement), bronchial hyper-responsiveness testing and consideration of alternative diagnoses. It is recommended that children with combined food allergy and asthma and any patient with late onset asthma where there is a suspicion of an occupational cause are referred for specialist assessment.

If another diagnosis is more likely

If an alternative diagnosis is suspected, investigation and management are to follow guidelines for that condition.

Co-morbidity: asthma and COPD

A proportion of patients with asthma will have both asthma and COPD e.g. they have airway obstruction that does not reverse to normal but also have substantial reversibility

Asthma 002.2 Reporting and verification

See indicator wording for requirement criteria.

Prepared By Jean Keenan