Billing and Coding: Diagnostic Aerosol or Vapor Inhalation

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L33969 Diagnostic Aerosol or Vapor Inhalation. Please refer to the LCD for reasonable and necessary requirements. Coding Guidance Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier. Documentation Requirements All documentation must be maintained in the patient's medical record and made available to the contractor upon request. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed. Documentation that the service was performed for sputum induction/mobilization or bronchodilation for diagnostic purposes must be included in the patient’s medical record. This information is normally found in the office/progress notes, hospital notes, and/or procedure report.