Quality Corner: CPT® Category II Codes - Collaborating for enhanced patient care

Comprehensive Diabetes Care

Whether or not patient age 18-75 years 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

Whether or not patient age 18-75 years most recent A1c level is controlled.

• 3044F - Most recent hemoglobin A1c level < 7.0%

• 3051F - Most recent hemoglobin A1c (HbA1c)
level ≥ to 7.0% and < 8.0%

• 3052F - Most recent hemoglobin A1c (HbA1c) level ≥ to 8.0% and ≤ to 9.0%

• 3046F - Most recent hemoglobin A1c level > 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 a patient age 18-75 years 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

Whether or not the patient aged 18 years and older with a diagnosis of hypertension has:

• a blood pressure reading < 140 mm Hg systolic and < 90 mm Hg diastolic

OR

• a blood pressure reading ≥ 140 mm Hg systolic and < 90 mm Hg diastolic and prescribed 2 or more anti-hypertensive agents during the most recent visit

• 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 to 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 last menstrual period – 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