Policy Updates Reimbursement PoliciesMedicaid Managed CareApril 10, 2024

CPT Category II Code Additional Reimbursements for Ohio Medicaid Managed Care

Providers can earn up to an additional $20 per Medicaid member, per service on health and wellness services provided to such members of Anthem by documenting CPT® Category II codes in the medical record and submitting the information in their claims. The use of CPT Category II codes benefits the healthcare system by providing more specific information about healthcare encounters. This data can be used to help providers work more efficiently and effectively in the best interest of each patient.

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. It is earned by completing the criteria for billing the CPT Category II codes listed in Table 1 below, including the corresponding diagnosis codes.

CPT Category II codes eligible for reimbursement must be billed with one of the following outpatient visit codes: 99202-99215.

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:

  • Better tracking and management of patient care needs from the use of detailed information provided with the billing of CPT Category II codes.
  • Providing complete diagnosis data that is received on a claim.

Table 1

CPT II code to include on claim

Description

Diagnosis category code to include on claim

Criteria

2024

pay

2015F

Asthma impairment assessment

J45.20 to J45.998

  • Provider conducts office evaluation for a member with asthma.
  • Provider performs asthma impairment assessment (for example, symptom frequency and pulmonary function) during the visit.
  • Provider reports appropriate office visit, diagnosis code(s), and Category II code 2015F.

$20

3023F

Spirometry results documented and reviewed

J40 to J44.9

  • Provider conducts office evaluation for a member with a chronic respiratory condition.
  • Provider documents and reviews spirometry results in the medical record.
  • Provider reports appropriate office visit, diagnosis code(s), and Category II code 3023F.

$20

3117F

For patients who have congestive heart failure: heart failure disease-specific structured assessment tool completed

I50 to I50.9

  • Provider conducts office evaluation for a member with a heart condition.
  • Provider completes heart failure disease-specific structured assessment tool (includes lab tests, examination procedures, radiologic examination, and/or results and medical decision-making).
  • Provider reports appropriate office visit, diagnosis code(s), and Category II code 3117F.

$20

0513F

For patients who have hypertension: elevated blood pressure plan of care

I10-I13, I-15-I16.9, N18.1-N18.9

E08.00-E11, E13-E13.9

  • Provider conducts office evaluation for a member with hypertension or hypertensive diseases.
  • Provider completes and documents elevated blood pressure plan of care.
  • Provider reports appropriate office visit, diagnosis code(s), and Category II code 0513F.

$20

3011F

Lipid panel results documented and reviewed

I25 to I25.9

  • Provider conducts office evaluation.
  • Provider documents and reviews lipid panel results in the medical record.
  • Provider reports appropriate office visit, diagnosis code(s), and Category II code 3011F.

$20

2014F

Mental status assessed (normal/
mildly impaired/
severely impaired) (CAP)1

F90.0 to F90.9

  • Provider conducts office evaluation for a member with ADD or ADHD.
  • Provider completes and documents mental status assessment.
  • Provider reports appropriate office visit, diagnosis code(s), and Category II code 2014F.

$20

3085F

Suicide risk assessed (MDD)1

F32.0 to F33.9

  • Provider conducts office evaluation for a member with major depressive disorder.
  • Provider completes and documents assessment of suicide risk.
  • Provider reports appropriate office visit, diagnosis code(s), and Category II code 3085F.

$20

3044F

For patients who have diabetes: most recent HbA1c less than 7

E08.00-E13.9

  • Provider conducts office evaluation for a member with diabetes mellitus (any type).
  • Provider completes and documents hemoglobin A1C results when less than 7.
  • Provider reports appropriate office visit, diagnosis code(s), and Category II code 3044F.

$20

3046F

For patients who have diabetes: most recent HbA1c
greater than 9

E08.00-E13.9

  • Provider conducts office evaluation for a member with diabetes mellitus (any type).
  • Provider completes and documents hemoglobin A1C results when greater than 9.
  • Provider reports appropriate office visit, diagnosis code(s), and Category II code 3046F.

$20

3051F

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

E08.00-E13.9

  • Provider conducts office evaluation for a member with diabetes mellitus (any type).
  • Provider completes and documents hemoglobin A1C results 7 to 8.
  • Provider reports appropriate office visit code, diagnosis code(s), and Category II code 3051F.

$20

3052F

Most recent hemoglobin A1c (HbA1c) level greater than or equal to 8.0% and less than 9.0% (DM)2

E08.00-E13.9

  • Provider conducts office evaluation for a member with diabetes mellitus (any type).
  • Provider completes and documents hemoglobin A1C results when 8 to 9.
  • Provider reports appropriate office visit code, diagnosis code(s), and Category II code 3052F.

$20

3475F

Disease prognosis for rheumatoid arthritis assessed, poor prognosis documented

M05 to M06.9

  • Provider conducts office evaluation for a member with rheumatoid arthritis.
  • Provider completes and documents rheumatoid arthritis assessment with a poor prognosis.
  • Provider reports appropriate office visit, diagnosis code(s), and Category II code 3475F.

$20

3476F

Disease prognosis for rheumatoid arthritis assessed, good prognosis documented

M05 to M06.9

  • Provider conducts office evaluation for a member with rheumatoid arthritis.
  • Provider completes and documents rheumatoid arthritis assessment with a good prognosis.
  • Provider reports appropriate office visit, diagnosis code(s), and Category II code 3476F.

$20

3500F

CD4+ cell count or CD4+ cell percentage documented as performed (HIV)5

B20, Z21, B97.35, O98.7

  • Provider conducts office evaluation for a member with HIV/AIDS-related diagnosis.
  • Provider completes and documents CD4+ cell count or CD4+ cell percentage in the medical record.
  • Provider reports appropriate office visit, diagnosis code(s), and Category II code 3500F.

$20

3066F

Documentation of treatment for nephropathy (for example, patient receiving dialysis, patient being treated for)

I1A0, N04.0-N08.0;

N10-N18.9; E08.00-E11.9; E13.00-E13.9

  • Provider conducts office evaluation for a member with nephropathy or CKD diagnosis.
  • Provider completes and documents treatment for nephropathy/CKD in the medical record.
  • Provider reports appropriate office visit, diagnosis code(s), and Category II code 3066F.

$20

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PUBLICATIONS: May 2024 Provider Newsletter