The American Medical Association has an alphabetical listing of clinical conditions with which measures and CPT Category II codes are associated. The use of CPT Category II Codes and ICD-10-CM codes can reduce the number of medical records that we request during the HEDIS® medical record review season (January – May each year), thus reducing the administrative burden on physician offices.

 

Below are some commonly used codes for your convenience.

Measure

Description

CPT II Code

Exclusions

Comprehensive Diabetes Care

Whether or not  patient age 18-75 had screening or monitoring for diabetic retinal disease

2022F - Dilated retinal eye exam with interpretation by ophthalmologist or optometrist documented and reviewed with evidence of retinopathy


2023F -
Dilated retinal eye exam with interpretation by ophthalmologist or optometrist documented and reviewed without retinopathy


3072F
- Low risk for retinopathy (no evidence of retinopathy in the prior year)

Documentation of gestational diabetes or steroid-induced diabetes

Comprehensive Diabetes Care

For patient age 18-75, whether or not the most recent A1c level is controlled

3044F - Most recent hemoglobin A1c level less than 7.0%


3051F
- Most recent hemoglobin A1c (HbA1c) level greater than or equal to 7.0% and less than 8.0%


3052F
Most recent hemoglobin A1c (HbA1c) level greater than or equal to 8.0% and less than or equal to 9.0%


3046F
Most recent hemoglobin A1c level greater than 9.0%

  • Report one of the four Category II codes listed and use the date of service as the date of the test, not the date of the reporting of the Category II code.

  • Documentation of medical reasons for not pursuing tight control of A1c level (i.e., steroid-induced or gestational diabetes, frailty and/or advanced illness)

Comprehensive Diabetes Care

Whether or not patient age 18-75 received urine protein screening or medical attention for nephropathy

3060F - Positive microalbuminuria test documented and reviewed


3061F -
Negative microalbuminuria test result documented and reviewed


3062F -
Positive macroalbuminuria test result documented and reviewed

 
3066F - Documentation of treatment for nephropathy

  • Documentation of gestational diabetes or steroid induced diabetes

Controlling High Blood Pressure

During the most recent visit, whether or not a patient age 18 years or older with a diagnosis of hypertension had:

a blood pressure reading less than 140 mm Hg systolic and less than 90 mm Hg diastolic OR

a blood pressure reading greater than or equal to 140 mm Hg systolic and less than 90 mm Hg diastolic, and prescribed 2 or more anti-hypertensive agents

3074F - Most recent systolic blood pressure < 130 mm Hg

3075F - Most recent systolic blood pressure 130 to 139 mm Hg


3077F -
Most recent systolic blood pressure ≥ 140 mm Hg


3078F
- Most recent diastolic blood pressure < 80 mm Hg


3079F
- Most recent diastolic blood pressure 80 – 89 mm Hg


3080F -
Most recent diastolic blood pressure ≥ 90 mm Hg


4145F
- Two or more anti-hypertensive agents prescribed or currently being taken

  • Report one of the three systolic codes.
  • Report one of the three diastolic codes.

  • Documentation of reason(s) for not prescribing 2 or more anti-hypertensive medications:
    • Medical (i.e., allergy, intolerant, postural hypotension or other reason)
    • Patient (i.e., patient declined, or other patient reason)
    • System (i.e., financial or other system reason)

Timeliness of Prenatal Care

Women who had live births between November 6 of the year prior to the measurement year and November 5 of the measurement year, who were continuously enrolled at least 43 days prior to delivery through 56 days after delivery

0500F - Initial prenatal care visit (report at first prenatal encounter with health care professional providing obstetrical care. (Report also date of visit and, in a separate field, the date of the last menstrual period – (LMP))

 

0501F - Prenatal flow sheet documented in medical record by first prenatal visit (documentation includes at minimum blood pressure, weight, urine protein, uterine size, fetal heart tones, and estimated date of delivery). Report also: date of visit and, in a separate field, the date of the LMP (Note: If reporting 0501F Prenatal flow sheet, it is not necessary to report 0500F Initial prenatal care visit)

 

Timeliness of Postpartum Care

Number of women in the denominator who had a postpartum visit on or between 21 days and 56 days after delivery. Denominator: Women who had live births between November 6 of the year prior to the measurement year and November 5 of the measurement year

0503F - Postpartum care visit

 

CPT® is a registered trademark of the American Medical Association Copyright 2020 American Medical Association. All rights reserved.

 

460-0620-PN-GA



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June 2020 Anthem Provider News - Georgia