CPT 2015F: Asthma Control Assessment and Documentation

CPT code 2015F documents a clinician’s assessment that an asthma patient’s symptoms are under control and records findings across all required assessment domains; this represents an asthma control assessment service typically delivered in an outpatient clinic or office visit setting where the provider evaluates symptom control and documents the assessment elements for clinical records and quality reporting.

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Clinical & Coding Specifications

Clinical Context

A 35-year-old patient with a history of persistent asthma presents to a primary care clinic for a routine follow-up visit to assess asthma control. The patient reports intermittent wheeze, increased rescue inhaler use (albuterol twice weekly), occasional daytime symptoms, and no recent hospitalizations or systemic steroid courses. The provider performs a focused history including symptom frequency, night awakenings, activity limitation, rescue inhaler use, and exacerbation history. Physical exam emphasizes respiratory assessment (inspection, auscultation for wheezes, respiratory rate, and accessory muscle use). The provider reviews current medications (inhaled corticosteroid, long-acting bronchodilator), adherence, inhaler technique, and triggers (allergens, smoke). Objective measures may include peak expiratory flow rate and spirometry if available. The clinician documents assessment of asthma control across all elements—symptoms, exacerbations, lung function, medication adherence—and documents a plan which could include adjustments to controller therapy, an asthma action plan, education, and follow-up. Typical sites of service are outpatient primary care or specialty ambulatory clinics. Typical service type: evaluation and management focused on chronic disease control assessment and documentation.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`94010`	Breathing capacity test; spirometry, including graphic records, total and timed vital capacity, expiratory flow rate measurement(s), with interpretation and report	Often performed to assess lung function when documenting asthma control and to guide treatment adjustments
`94375`	Respiratory flow volume loop (if separately reportable)	May be used when more detailed pulmonary function testing is needed for control assessment
`94640`	Pressurized or non-pressurized inhalation treatment for acute airway obstruction; nebulizer or metered dose inhaler	May be provided during the visit for acute symptom relief noted at assessment
`99070`	Supplies and materials provided by the physician over and above those usually included with the services of the physician	Used for devices or educational materials such as peak flow meters supplied at the visit
`99406`	Smoking and tobacco use cessation counseling visit, intermediate, greater than 3 minutes up to 10 minutes	Often performed in conjunction with asthma assessments when smoking is an identified trigger

Related Modifiers

6 rows

Modifier	Description	When to Use
25	CPT modifier 25 indicates that on the same day as another procedure or service, the same physician or other qualified health care professional provided a significant, separately identifiable…	- When to apply: Use modifier 25 only on an E/M code to indicate the same provider delivered a significant, separately identifiable E/M service on the same day as another procedure or service — i.e.,…
59	Modifier 59 indicates a distinct procedural service when two procedures that are not normally billed together are clinically and procedurally separate. The CPT definition (as reiterated by CMS)…	- Use modifier -59 to report a distinct procedural service when documentation supports that the procedure reported is not normally billed together with another service on the same day because of a…
24	Modifier 24 denotes an unrelated evaluation and management (E/M) service performed by the same physician or qualified healthcare professional during a postoperative global period. Per CPT guidance,…	- Use modifier 24 when you report an evaluation and management (E/M) service performed by the same physician or same-specialty group during a procedure’s postoperative global period that is unrelated…
76	Modifier -76, Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional, is appended when the same provider performs an identical, medically necessary procedure or…	- Use modifier -76 when the same physician or other qualified health care professional performs an identical procedure or service a second (or subsequent) time on the same date of service and the…
77	Modifier 77 indicates that a previously performed procedure or service was legitimately repeated by a different physician or other qualified health care professional. The AMA’s CPT definition…	- Use modifier 77 when a basic procedure or service already performed is repeated by a different physician or other qualified health care professional (for example, a second provider independently…
95	Modifier 95 indicates that a service was provided via synchronous, real‑time audio‑video telehealth rather than in‑person. Per CMS, AAPC and professional associations, append modifier 95 to claim…	- Use modifier 95 to indicate a service was furnished via synchronous, real‑time audiovisual telehealth (a live audio‑video conference between patient and provider) rather than in‑person. - Pair…

Related Provider Taxonomies

8 rows

Taxonomy Code
207Q00000X
207R00000X
207RH0000X
207K00000X
2084P0800X
305R00000X
282NR1301X
213ES0000X

Related ICD-10-CM Codes

27 rows

ICD-10-CM Code	Description
B34.9	Viral infection, unspecified
J20.9	Acute bronchitis, unspecified
J44.9	Chronic obstructive pulmonary disease, unspecified
J45.20	Mild intermittent asthma, uncomplicated
J45.21	Mild intermittent asthma with (acute) exacerbation
J45.22	Mild intermittent asthma with status asthmaticus
J45.30	Mild persistent asthma, uncomplicated
J45.31	Mild persistent asthma with (acute) exacerbation
J45.32	Mild persistent asthma with status asthmaticus
J45.40	Moderate persistent asthma, uncomplicated

Showing 1–10 of 27

Related Payer Policy Updates

Specialty: Pediatrics/Neonatology1 / 3

10 rows

Policy	Payer	Effective Date
Pediatric Neurodevelopmental and Autism Spectrum Disorder (ASD) Screening Corporate Medical Policy	bcbsvermont	2026-12-01
Inhaled Nitric Oxide Therapy (for New Mexico Only)	UnitedHealthcare	2026-10-01
Inhaled Nitric Oxide Therapy (for North Carolina Only)	UnitedHealthcare	2026-10-01
Inhaled Nitric Oxide Therapy (for Pennsylvania Only)	UnitedHealthcare	2026-10-01
Inhaled Nitric Oxide Therapy (for Kentucky Only)	UnitedHealthcare	2026-10-01
Clinical Policy: NICU Apnea Bradycardia Guidelines	Ambetter Nevada	2026-10-01
DRG Newborn Inpatient Stays - Facility	Blue Cross Blue Shield - Maine	2026-10-01
Pediatric Preventive Screening	Oscar Health	2026-10-01
Infant Nutritional Formula	Cigna	2026-09-15
Pediatric Preventive Screening	Blue Cross Blue Shield - New Mexico	2026-09-04

Related Codes

CPT-2000F-UNDEFINED-SERVICE

CPT 2000F: No Summary found

CPT-2001F-UNSPECIFIED-CLINICAL-SERVICE

CPT 2001F: No Summary Available

CPT-2002F-UNSPECIFIED-SERVICE

CPT 2002F: No Summary found for this code

CPT-2004F-UNDEFINED-SERVICE

CPT 2004F: Clinical/Quality Measure (No Summary Available)

CPT-2010F-UNSPECIFIED-SERVICE

CPT 2010F: No Summary found for this code

CPT-2014F-NO-SUMMARY-AVAILABLE

CPT 2014F: Short-interval Oxygen Saturation Assessment

CPT-2016F-ASTHMA-RISK-ASSESSMENT-AND-DOCUMENTATION

CPT 2016F: Asthma Risk Assessment and Documentation

CPT-2018F-UNDEFINED-SERVICE

CPT 2018F: No Summary Found

CPT-2019F-UNDEFINED-SERVICE

CPT 2019F: Procedure, specific descriptor unavailable

CPT-2020F-UNSPECIFIED-SERVICE

CPT 2020F: Prosthetic or Orthotic Device Evaluation

Showing 1–10 of 27

Frequently Asked Questions

References

1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.

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Clinical & Coding Specifications

Clinical Context

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`94010`	Breathing capacity test; spirometry, including graphic records, total and timed vital capacity, expiratory flow rate measurement(s), with interpretation and report	Often performed to assess lung function when documenting asthma control and to guide treatment adjustments
`94375`	Respiratory flow volume loop (if separately reportable)	May be used when more detailed pulmonary function testing is needed for control assessment
`94640`	Pressurized or non-pressurized inhalation treatment for acute airway obstruction; nebulizer or metered dose inhaler	May be provided during the visit for acute symptom relief noted at assessment
`99070`	Supplies and materials provided by the physician over and above those usually included with the services of the physician	Used for devices or educational materials such as peak flow meters supplied at the visit
`99406`	Smoking and tobacco use cessation counseling visit, intermediate, greater than 3 minutes up to 10 minutes	Often performed in conjunction with asthma assessments when smoking is an identified trigger

Related Modifiers

6 rows

Modifier	Description	When to Use
25	CPT modifier 25 indicates that on the same day as another procedure or service, the same physician or other qualified health care professional provided a significant, separately identifiable…	- When to apply: Use modifier 25 only on an E/M code to indicate the same provider delivered a significant, separately identifiable E/M service on the same day as another procedure or service — i.e.,…
59	Modifier 59 indicates a distinct procedural service when two procedures that are not normally billed together are clinically and procedurally separate. The CPT definition (as reiterated by CMS)…	- Use modifier -59 to report a distinct procedural service when documentation supports that the procedure reported is not normally billed together with another service on the same day because of a…
24	Modifier 24 denotes an unrelated evaluation and management (E/M) service performed by the same physician or qualified healthcare professional during a postoperative global period. Per CPT guidance,…	- Use modifier 24 when you report an evaluation and management (E/M) service performed by the same physician or same-specialty group during a procedure’s postoperative global period that is unrelated…
76	Modifier -76, Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional, is appended when the same provider performs an identical, medically necessary procedure or…	- Use modifier -76 when the same physician or other qualified health care professional performs an identical procedure or service a second (or subsequent) time on the same date of service and the…
77	Modifier 77 indicates that a previously performed procedure or service was legitimately repeated by a different physician or other qualified health care professional. The AMA’s CPT definition…	- Use modifier 77 when a basic procedure or service already performed is repeated by a different physician or other qualified health care professional (for example, a second provider independently…
95	Modifier 95 indicates that a service was provided via synchronous, real‑time audio‑video telehealth rather than in‑person. Per CMS, AAPC and professional associations, append modifier 95 to claim…	- Use modifier 95 to indicate a service was furnished via synchronous, real‑time audiovisual telehealth (a live audio‑video conference between patient and provider) rather than in‑person. - Pair…

Related Provider Taxonomies

8 rows

Taxonomy Code
207Q00000X
207R00000X
207RH0000X
207K00000X
2084P0800X
305R00000X
282NR1301X
213ES0000X

Related ICD-10-CM Codes

27 rows

ICD-10-CM Code	Description
B34.9	Viral infection, unspecified
J20.9	Acute bronchitis, unspecified
J44.9	Chronic obstructive pulmonary disease, unspecified
J45.20	Mild intermittent asthma, uncomplicated
J45.21	Mild intermittent asthma with (acute) exacerbation
J45.22	Mild intermittent asthma with status asthmaticus
J45.30	Mild persistent asthma, uncomplicated
J45.31	Mild persistent asthma with (acute) exacerbation
J45.32	Mild persistent asthma with status asthmaticus
J45.40	Moderate persistent asthma, uncomplicated

Showing 1–10 of 27

Related Payer Policy Updates

Specialty: Pediatrics/Neonatology1 / 3

10 rows

Policy	Payer	Effective Date
Pediatric Neurodevelopmental and Autism Spectrum Disorder (ASD) Screening Corporate Medical Policy	bcbsvermont	2026-12-01
Inhaled Nitric Oxide Therapy (for New Mexico Only)	UnitedHealthcare	2026-10-01
Inhaled Nitric Oxide Therapy (for North Carolina Only)	UnitedHealthcare	2026-10-01
Inhaled Nitric Oxide Therapy (for Pennsylvania Only)	UnitedHealthcare	2026-10-01
Inhaled Nitric Oxide Therapy (for Kentucky Only)	UnitedHealthcare	2026-10-01
Clinical Policy: NICU Apnea Bradycardia Guidelines	Ambetter Nevada	2026-10-01
DRG Newborn Inpatient Stays - Facility	Blue Cross Blue Shield - Maine	2026-10-01
Pediatric Preventive Screening	Oscar Health	2026-10-01
Infant Nutritional Formula	Cigna	2026-09-15
Pediatric Preventive Screening	Blue Cross Blue Shield - New Mexico	2026-09-04

Related Codes

CPT-2000F-UNDEFINED-SERVICE

CPT 2000F: No Summary found

CPT-2001F-UNSPECIFIED-CLINICAL-SERVICE

CPT 2001F: No Summary Available

CPT-2002F-UNSPECIFIED-SERVICE

CPT 2002F: No Summary found for this code

CPT-2004F-UNDEFINED-SERVICE

CPT 2004F: Clinical/Quality Measure (No Summary Available)

CPT-2010F-UNSPECIFIED-SERVICE

CPT 2010F: No Summary found for this code

CPT-2014F-NO-SUMMARY-AVAILABLE

CPT 2014F: Short-interval Oxygen Saturation Assessment

CPT-2016F-ASTHMA-RISK-ASSESSMENT-AND-DOCUMENTATION

CPT 2016F: Asthma Risk Assessment and Documentation

CPT-2018F-UNDEFINED-SERVICE

CPT 2018F: No Summary Found

CPT-2019F-UNDEFINED-SERVICE

CPT 2019F: Procedure, specific descriptor unavailable

CPT-2020F-UNSPECIFIED-SERVICE

CPT 2020F: Prosthetic or Orthotic Device Evaluation

Showing 1–10 of 27

Frequently Asked Questions

References

1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.

Published by

Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.

CPT 2015F: Asthma Control Assessment and Documentation

Sign up for cpt 2015F policy alerts

CPT 2015F: Asthma Control Assessment and Documentation

Sign up for cpt 2015F policy alerts

Clinical & Coding Specifications

Clinical Context

Related CPT Codes

Related Modifiers

Related Provider Taxonomies

Related ICD-10-CM Codes

Related Payer Policy Updates

Related Codes

What does CPT 2015F represent and when is it used?

Where and in what service context is 2015F typically reported?

Which modifiers may be appropriate when reporting 2015F?

What other CPT codes are commonly reported with an asthma control assessment?

Which ICD-10 diagnosis codes are relevant when billing 2015F?

References

Clinical & Coding Specifications

Clinical Context

Related CPT Codes

Related Modifiers

Related Provider Taxonomies

Related ICD-10-CM Codes

Related Payer Policy Updates

Related Codes

What does CPT 2015F represent and when is it used?

Where and in what service context is 2015F typically reported?

Which modifiers may be appropriate when reporting 2015F?

What other CPT codes are commonly reported with an asthma control assessment?

Which ICD-10 diagnosis codes are relevant when billing 2015F?

References