CPT Category II update

Care providers can earn additional reimbursement on health and wellness services provided to Anthem members. Anthem is offering reimbursement for the use of CPT^® Category II codes to encourage continued improvements in member care. The use of CPT Category II codes benefits the healthcare system by providing more specific information about healthcare encounters, such as how data can be used to help Anthem care providers work more efficiently and effectively in the best interest of each member.

Reimbursement for the administrative work and effort of completing and reporting CPT Category II codes can only be claimed once per service, per member, per year and are earned by completing the criteria for billing the CPT Category II codes listed in Table 1.

CPT Category II codes must be billed with one of these outpatients visit codes: 99202 to 99215.

The additional reimbursement applies to physicians and qualified healthcare-allied practitioners, including PCPs, cardiologists, endocrinologists, pulmonologists, internal medicine practitioners, nephrologists, rheumatologists, nurse practitioners, physician assistants, obstetricians, federally qualified health centers, and rural health clinics.

What is a CPT Category II code?

• A CPT Category II code provides more detailed information about the clinical service(s) performed.
• CPT Category II codes are billed similar to the way your office bills for regular CPT codes and are placed in the same location on the claim form.

Benefits of using CPT Category II codes include:

• A reduction in the need for Anthem to review your medical records by providing more detailed information through your claim submissions.
• Better tracking and management of member care needs from the use of detailed information provided with the billing of CPT Category II codes.

Next steps you need to take:

• Review the CPT Category II code billing opportunities in Table 1 to set up your billing system to bill us for the codes when applicable.
• Be sure that you meet the criteria for billing the CPT Category II codes in Table 1 by matching the diagnosis codes and age ranges and set up your billing system to bill appropriately.

Note: All CPT Category II codes are eligible for payment only once per member, per calendar year. Continuation of payment and payment rates for billing the CPT Category II codes will be evaluated annually.

If you have questions about this communication or need assistance with any other item, visit the Contact Us section at the bottom of our provider website (https://providers.anthem.com/ny) for
up-to-date contact information or call Provider Services at 800-450-8753.

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