Wiki CPT 94640 Inhalation treatment

[wkpotter6]

Hello,
Should there be a report or results used as documentation when billing for CPT 94640? Also, when billing for 94640, does the medication/supply come from the office (I bill for Internal Medicine) or could there be instances when the patient bring in their own medication? Hope this is not a dumb question, but it might be.

 

[marissa21p]

94640 Billing

Documentation to support 94640 does not have to have a specific report or result. The office note does need to include the inhalation treatment(s), drug used, and if it helped. Usually this will be followed up with spirometry, which does include a report. If the patient brings the drug (ex. albuterol) you would not bill, however billing for the drug is always acceptable if it is truly coming from the office. Always include the NDC code and have the lot # documented in the practice log in case of a recall or audit.
Marissa Padworny CPC