MedicaidOctober 23, 2024
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, rural health clinics, and urgent care facilities.
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 similarly 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.
Table 1
CPT II code |
Description |
Diagnosis category code |
Criteria |
2024 pay |
3117F |
For patients who have congestive heart failure: heart failure
|
I50.1–I50.9 |
|
$20 |
0513F |
For patients who have hypertension: elevated blood pressure plan of care |
I10–I16.9, N18.1–N18.9, E08.00–E13.9 |
|
$20 |
3011F |
Lipid panel results documented and reviewed |
I25.10–I25.9 |
|
$20 |
3044F |
For patients who have diabetes: most recent HbA1c less than 7 |
E08.00–E13.9 |
|
$20 |
3046F |
For patients who have diabetes: most recent HbA1c greater than 9 |
E08.00–E13.9 |
|
$20 |
3051F |
Most recent HbA1c level greater than or equal to 7% and less than 8% |
E08.00–E13.9 |
|
$20 |
3052F |
Most recent HbA1c level greater than or equal to 8% and less than 9% |
E08.00–E13.9 |
|
$20 |
2014F |
Mental status assessed (normal, mildly impaired, or severely impaired) (cap) |
F90.0–F90.9 |
|
$20 |
3085F |
Suicide risk assessed (MDD) |
F32.0–F33.9 |
|
$20 |
3066F |
Documentation of treatment for nephropathy (for example, patient receiving dialysis) |
N04.0–N18.9, E08.00–E11.9, E13.00–E13.9 |
|
$20 |
3023F |
Spirometry results documented and reviewed |
J40–J44.9 |
|
$20 |
2022F |
Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy |
E08.00– E13.9 |
|
$20 |
2023F |
Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy |
E08.00–E13.9 |
|
$20 |
2024F |
Seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy (DM) |
E08.00–E13.9 |
|
$20 |
2025F |
Seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy (DM) |
E08.00–E13.9 |
|
$20 |
2026F |
Eye imaging validated to match diagnosis from seven standard field stereoscopic retinal photos results documented and reviewed; with evidence of retinopathy (DM) |
E08.00–E13.9 |
|
$20 |
2033F |
Eye imaging validated to match diagnosis from seven standard field stereoscopic retinal photos results documented and reviewed; without evidence of retinopathy (DM) |
E08.00–E13.9 |
|
$20 |
3074F |
For patients with the most recent systolic blood pressure reading < 130 mm Hg |
I10–I16.9,
|
|
$20 |
3075F |
For patients with the most recent systolic blood pressure
|
I10–I16.9,
|
|
$20
|
3078F |
For patients with the most recent diastolic blood pressure < 80 mm Hg |
I10–I16.9,
|
|
$20 |
3079F |
For patients with the most recent diastolic blood pressure 80–89 mm Hg |
I10–I16.9, N18.1–N18.9 |
|
$20 |
3077F |
Most recent systolic blood pressure greater than or equal to 140 mm Hg |
I10–I16.9, E08.00–E13.9 |
|
$20 |
3080F |
Most recent systolic blood pressure greater than or equal to 90 mm Hg |
I10–I16.9, E08.00–E13.9 |
|
$20 |
0500F |
Report at the first prenatal encounter with healthcare professionals providing obstetrical care. In a separate field, report the date of the last menstrual period (LMP) |
N/A |
|
$25 |
0501F |
Prenatal flow sheet documented in the medical record by the first prenatal visit
|
N/A |
|
$25 |
0503F |
For patients who complete a postpartum visit between seven and 84 days after delivery. |
Z39.2 |
|
$25 |
Medicaid services provided by Anthem Blue Cross and Blue Shield HP, trade name of Anthem HP, LLC.
Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
NYBCBS-CD-071451-24, NYBCBS-CD-067002-24
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