What CPT codes are used for asthma management visits?

Use E/M codes 99212-99215 based on MDM complexity. Well-controlled asthma with medication review typically supports 99213; poorly controlled with treatment adjustment supports 99214. Spirometry uses 94010 (basic) or 94060 (pre/post bronchodilator). Nebulizer treatment uses 94640. Add modifier 25 when performing procedures with E/M on same day.

What asthma control documentation is required for quality measures?

Document: symptom frequency (daytime symptoms days/week, nighttime awakenings/month), rescue inhaler use frequency, activity limitation, lung function (FEV1 or peak flow percentage), and asthma control classification (well-controlled, not well-controlled, very poorly controlled). Use standardized tools like ACT (Asthma Control Test) or ACQ (Asthma Control Questionnaire).

How should inhaler technique assessment be documented?

Document: observation of technique, specific errors identified (coordination, breath holding, spacer use), education provided on correct technique, and patient demonstration of understanding. Poor technique is a leading cause of poor control. Document counseling on spacer use with MDIs and proper device-specific technique for DPIs.

What documentation supports asthma action plan billing?

Document: zones defined (green/yellow/red with specific criteria), medications for each zone, patient-specific peak flow or symptom triggers for zone changes, when to seek emergency care, and that written plan was provided and reviewed with patient. Action plan review supports E/M complexity and demonstrates quality care.

How do I document medical necessity for controller medication changes?

Document: current control status with specific metrics (symptoms/week, nighttime symptoms, rescue use, FEV1), current regimen with doses and adherence, reason for change (poor control, side effects, step-up or step-down per guidelines), and expected benefit of new regimen. Reference GINA or NAEPP guidelines when supporting treatment decisions.

Asthma Management Template - Chronic Care Visit

Primary Care — Asthma Management Visit Template

Primary Care Family Medicine Updated: 11/7/2025

The Asthma Management Visit Template is designed for primary care providers, pediatricians, and pulmonologists managing patients with asthma. This focused template documents asthma control assessment, medication management, environmental trigger identification, action plan review, and patient education. The template supports appropriate billing for chronic disease management visits and includes sections for asthma control assessment using standardized tools, symptom frequency and severity, medication adherence and technique, environmental triggers and exposure, physical examination including respiratory assessment, peak flow measurements if applicable, assessment of asthma control level, medication adjustments including controller and rescue medications, asthma action plan review and updates, patient education on trigger avoidance and medication use, and follow-up planning. This template ensures comprehensive asthma care, supports asthma control goals, facilitates medication optimization, and improves patient outcomes through systematic management. Ideal for primary care practices managing asthma, pediatric practices, pulmonology practices, and practices participating in asthma quality improvement programs.

Visit Information

Visit type: Routine asthma follow-up / Acute asthma exacerbation
Date of last asthma visit: [Date]

Asthma Control Assessment

Symptom frequency: [Days per week with symptoms]
Nighttime symptoms: [Nights per week]
Activity limitation: None / [Specify]
Rescue inhaler use: [Times per week]
Asthma control: Well-controlled / Not well-controlled / Very poorly controlled

Symptom Review

Cough: None / [Frequency]
Wheezing: None / [Frequency]
Shortness of breath: None / [Frequency]
Chest tightness: None / [Frequency]
Exercise tolerance: Good / Limited

Medication Review

Controller medications: [List with dosages and adherence]
Rescue medications: [List with frequency of use]
Inhaler technique: Correct / Needs review
Spacer use: Yes / No
Medication side effects: None / [Specify]

Environmental Triggers

Known triggers: [Dust, pollen, pets, smoke, exercise, etc.]
Exposure: [Current exposure to triggers]
Home environment: [Smoking, pets, etc.]

Physical Examination

Vital signs: BP, HR, RR, Temp, SpO2
General: Appearance, respiratory distress
Respiratory: Rate, effort, breath sounds (clear / wheezes / decreased), accessory muscle use
Cardiovascular: [If relevant]
Other: [Relevant findings]

Peak Flow

Baseline: [If known]
Today: [If measured]
Percent of personal best: [If applicable]

Assessment

1) Asthma, [Severity classification]

Control: Well-controlled / Not well-controlled / Very poorly controlled
Triggers: [Identified triggers]

2) [Other diagnoses as applicable]

Plan

1) Asthma management:

Controller medications: Continue / Adjust / Add: [specify]
Rescue medications: Continue / Adjust: [specify]
Action plan: Reviewed / Updated

2) Trigger avoidance: [Specific recommendations]
3) Patient education: [Medication technique, trigger avoidance, action plan, when to seek care]
4) Follow-up: Return in [timeframe] for asthma follow-up / Sooner if: [specify]

Patient Instructions

Asthma action plan reviewed. Medication technique reviewed. Warning signs discussed. Patient verbalized understanding.