G9697 HCPCS: Reimbursement & Policy Benchmarks | OpenPayer

Summary & Overview

HCPCS G9697: Documentation of Reason for Not Prescribing Long-Acting Inhaled Bronchodilator

HCPCS Level II code G9697 records clinician documentation of the patient’s reason(s) for not prescribing a long-acting inhaled bronchodilator. The code is relevant to ambulatory management of chronic respiratory conditions where long-acting inhaled bronchodilators are guideline-recommended therapy; it provides a standardized way to capture exceptions to prescribing. Nationally, use of exception-documentation codes supports quality measurement, care coordination, and payer medical record review processes.

Key payers covered in this review include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise explanation of the code’s clinical context and service settings, an overview of payer coverage considerations, common modifiers that may appear on claims, and pointers to typical documentation elements. The publication outlines where G9697 fits into respiratory care workflows and how it is used to record a patient-centered rationale for withholding a long-acting inhaled bronchodilator.

This summary provides benchmarks and policy-relevant context for coders, clinicians, and compliance officers: how the code is intended to be applied, what type of encounters generate it, and what information should be present in the medical record to support its use. Data not available in the input will be noted where applicable.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareG9697HCPCS Level IIinhaled bronchodilatorrespiratory caremedication documentationambulatory carequality measurementclinical documentation

Billing Code Overview

HCPCS Level II code G9697 documents the patient's reason(s) for not prescribing a long-acting inhaled bronchodilator. This code captures clinician documentation that explains why a guideline-recommended long-acting inhaled bronchodilator was not prescribed for a patient.

Service Type: Clinical documentation / decision support related to inhaled bronchodilator prescribing

Typical Site of Service: Outpatient clinic or ambulatory care setting where inhaled bronchodilator management and medication decisions are made

Clinical & Coding Specifications

Clinical Context

A patient with chronic obstructive pulmonary disease (COPD) or chronic asthma presents for a longitudinal outpatient follow-up visit in a primary care or pulmonary clinic. The clinician reviews the patient’s current inhaled medication regimen and assesses symptoms, exacerbation history, medication adherence, inhaler technique, comorbidities, and potential contraindications. After shared decision-making, the clinician determines that a long-acting inhaled bronchodilator (LABA or LAMA) is not being prescribed. The clinician documents the specific reason(s) for not prescribing a long-acting inhaled bronchodilator and uses billing code G9697 to reflect that documentation. Typical workflow steps include: review of prior medications and recent pulmonary function or peak flow results, evaluation for drug interactions or intolerance, assessment of access or cost barriers, discussion of alternative therapies or short-acting inhaler use, and clear documentation of the clinician’s rationale in the medical record. Typical sites of service are outpatient clinic, ambulatory surgery center (if preoperative evaluation), or telemedicine visit when carried out during virtual chronic disease management.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when documentation supports substantially greater physician work related to the decision and counseling not to prescribe a long-acting inhaled bronchodilator.

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HCPCS-G2006-POST-DISCHARGE-HOME-VISIT-20-MIN

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HCPCS-G2156-TD-TDAP-VACCINATION-STATUS-OR-CONTRAINDICATION

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HCPCS-G1011-CLINICAL-DECISION-SUPPORT-TOOL-APPROPRIATE-USE

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HCPCS-G9671-DIABETIC-RETINOPATHY-MEASURES-GROUP-INTENT-TO-REPORT

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HCPCS-G8581-NO-ANTIPLATELET-MEDICATION-AT-DISCHARGE

HCPCS G8581: No Antiplatelet Medication at Discharge

HCPCS-G2140-POSTOPERATIVE-LEG-PAIN-OUTCOME-ASSESSMENT

HCPCS G2140: Postoperative Leg Pain Outcome Assessment

HCPCS-G9606-INTRAOPERATIVE-CYSTOSCOPY-LOWER-TRACT-INJURY-EVALUATION

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HCPCS-G0060-ALLERGY-IMMUNOLOGY-MIPS-SPECIALTY-SET

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HCPCS-G9541-FILTER-REMOVED-WITHIN-3-MONTHS

HCPCS G9541: Filter Removed Within 3 Months of Placement

Showing 1–10 of 1996

Taxonomy Code	Specialty	Notes
207RC0000X	Pulmonary Disease	Pulmonologists commonly document medication decisions for chronic airway disease.
207LP2900X	Internal Medicine	Primary care internists often manage COPD/asthma medication regimens and document reasons for not prescribing.
363LP0800X	Nurse Practitioner	Advanced practice providers in primary or pulmonary clinics frequently document these clinical decisions.
207RH0002X	Allergy & Immunology	Specialists may document non-prescription when asthma management involves allergen-directed therapy instead.
2084P0800X	Family Medicine	Family physicians commonly evaluate chronic respiratory disease and document rationale for medication choices.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`J44.9`	Chronic obstructive pulmonary disease, unspecified	COPD is a primary indication for long-acting inhaled bronchodilators; documentation may explain why a LABA/LAMA was not prescribed.
`J45.909`	Unspecified asthma, uncomplicated	Asthma management decisions include consideration of long-acting bronchodilators; clinicians document reasons for not prescribing when appropriate.
`R05`	Cough	Symptom that prompts evaluation of inhaled bronchodilator need; documentation may state that cough alone did not justify a long-acting agent.
`Z79.899`	Other long term (current) drug therapy	Relevant when existing medication regimens or long-term therapies influence the decision not to initiate an additional long-acting bronchodilator.
`Z51.81`	Encounter for therapeutic drug level monitoring	Relevant when concurrent drug monitoring or toxicity concerns lead to withholding a long-acting inhaled bronchodilator.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99213`	Office or other outpatient visit for the evaluation and management of an established patient, typically 15 minutes	Common E/M visit code used when documenting the rationale for not prescribing a long-acting inhaled bronchodilator during a problem-focused or expanded problem-focused visit.
`99214`	Office or other outpatient visit for the evaluation and management of an established patient, typically 25 minutes	Used when prolonged evaluation and counseling support more complex decision-making documented for not prescribing a long-acting inhaled bronchodilator.
`99406`	Smoking and tobacco use cessation counseling, intermediate, greater than 3 minutes up to 10 minutes	Often provided alongside inhaler therapy discussion when tobacco cessation affects bronchodilator decisions.
`94010`	Spirometry, including graphic record, when performed	Pulmonary function testing that may be performed before deciding on long-acting bronchodilator therapy; results can inform the decision and be referenced in `G9697` documentation.
`94640`	Demonstration and/or evaluation of patient utilization of an inhalation device	Used when the clinician evaluates or trains inhaler technique and documents that poor technique or inability to use device is a reason for not prescribing a long-acting bronchodilator.

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