What is the purpose of CPT II codes?
CPT II codes help define nationally established performance measures by facilitating data collection regarding the quality of care rendered.
CPT II codes describe:
• Clinical components, such as those typically included in evaluation, management, or other clinical services;
• Results from clinical laboratory or radiology tests and other procedures;
• Identified processes intended to address patient safety practices; or
• Services reflecting compliance with state or federal law.
Why use CPT Category II codes?
CPT Category II codes can relay important information related to health outcome measures such as
** CVD cholesterol management
** Controlling blood pressure
** Comprehensive diabetes care
** Tobacco cessation
What do we hope to achieve?
Amerigroup Kansas strives to ensure that we promote the most efficient processes for our providers while continuously improving the quality of care and services that our members receive. By increasing the use of CPT Level II codes, we hope to:
** Improve the health status of our members
** Monitor and ensure our members receive seamless, continuous and appropriate care throughout the continuum of care
** Improve the provider experience
How do I identify a CPT II code?
CPT II codes contain five characters – the first four numerical characters are followed by an alphabetical fifth character, the letter ‘F’.
The current set of CPT II codes contains the following sub-categories:
• Composite Measures 0001F – 0015F
• Patient Management 0500F – 0575F
• Patient History 1000F – 1220F
• Physical Examination 2000F – 2050F
• Diagnostic/Screening Processes or Results 3006F – 3573F
• Therapeutic, Preventive, or Other Interventions 4000F – 4306F
• Follow-Up or Other Outcomes 5005F – 5100F
• Patient Safety 6005F – 6045F
• Structural 7010F – 7025F
Why should my organization use CPT II Codes?
Not only can using CPT II codes ease the administrative burden of chart review for many HEDIS™ performance measures, use of these codes enables organizations to monitor internal performance for key measures throughout the year, rather than once per year as measured by health plans and Pay for Performance. By identifying opportunities for improvement, interventions can be implemented to improve performance during the service year.
How should my organization bill CPT II Codes?
CPT II codes are billed in the procedure code field; just as CPT Category I codes are billed. CPT II codes describe clinical components usually included in evaluation and management or clinical services and are not associated with any relative value. Therefore, CPT II codes are billed with a $0.00 billable charge amount.
NOTE: Once the lab results are received, please submit the appropriate Category II Code to PSHP.
Where can I find a list of CPT II Codes?
CPT II codes are released annually as part of the full CPT code set and are updated semi-annually in January and July by the AMA. The current listing of CPT II codes can be found on the AMA Web site at:
Category II Modifiers
Four Category II modifiers (1P, 2P, 3P, and 8P) are used to report services that were considered but not provided because of medical reason(s), patient choice, or system reasons. Modifier 1P (performance measure exclusion modifier due to medical reasons) is used to report that one of the performance measures was not performed, because it was not indicated (eg, already performed) or was contraindicated (eg, because of a patient’s allergy).
Modifier 2P (performance measure exclusion modifier due to patient choice) is used to report that the performance measure was not performed because of a patient’s religious, social, or economic reasons; the patient declined (ie, noncompliance with treatment); or other specific reasons.
Modifier 3P (performance measure exclusion modifier due to system reasons) is used to report that the performance measure was not performed because the payer does not cover the service, the resources to perform the service are not available, or other reasons attributable to the health care delivery system. These modifiers are only used with Category II codes and only when allowed based on the specific reporting instructions for each performance measure.
Modifier 8P (performance measure reporting modifier—action not performed, not otherwise specified) is used as a reporting modifier to allow the reporting of circumstances when an action described in a measure’s numerator is not performed and the reason is not otherwise specified
CPT Category II code short list HEDIS/Other measure Indicator description CPT Category ll codes*
Adult BMI BMI assessed/documented 3008F
CVD cholesterol management LDL test & level 3048F, 3049F, 3050F
Controlling blood pressure Blood pressure readings 3074F, 3075F, 3077F, 3078F, 3079F, 3080F
Comprehensive diabetes care A1c test & A1c level 3044F, 3045F, 3046F
Eye Exam 2022F, 2024F, 2026F
LDL test & level 3048F, 3049F, 3050F
Nephropathy screening 3060F, 3061F, 3062F, 4009F, 3066F
Blood pressure readings 3074F, 3075F, 3077F, 3078F, 3079F 3080F
Tobacco cessation Screening, counseling, intervention 1031F, 1032F, 1033F, 1034F, 1035F, 1036F, 4001F, 4004F
Fall risk assessment Assessment, plan of care 0518F, 1100F, 1101F
F code Code descriptor(s) From AMA
4010F Angiotensin converting enzyme (ACE) inhibitor or Angiotensin receptor blocker (ARB) therapy prescribed or currently being taken
3080F Most recent diastolic blood pressure 90 mm Hg
3079F Most recent diastolic blood pressure 80 – 89 mm Hg
3078F Most recent diastolic blood pressure < 80 mm Hg
3077F Most recent systolic blood pressure 140 mm Hg
3075F Most recent systolic blood pressure 130 to 139 mm Hg
3074F Most recent systolic blood pressure < 130 mm Hg
3072F Low risk for retinopathy (no evidence of retinopathy in the prior year)
3066F Documentation of treatment for nephropathy (e.g. patient receiving dialysis, patient being treated for ESRD, CRF, ARF or renal insufficiency, any visit to a nephrologist)
3062F Positive macroalbuminuria test result documented and reviewed
3061F Negative microalbuminuria test result documented and reviewed
3060F Positive microalbuminuria test result documented and reviewed
3050F Most recent LDL -C 130 mg/dL
3049F Most recent LDL -C 100-129 mg/dL
3048F Most recent LDL -C < 100 mg/dL
3046F Most recent hemoglobin A1c (HbA1c) level > 9.0%
3045F Most recent hemoglobin A1c (HbA1c) level 7.0% to 9.0%
3044F Most recent hemoglobin A1c (HbA1c) level < 7.0%
2026F Eye imaging validated to match diagnosis from seven standard field stereoscopic photos results documented and reviewed
2024F Seven standard field stereoscopic photos with interpretation by an ophthalmologist or optometrist documented and reviewed
2022F Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed
1170F Functional status assessed
1160F Review of all medications by a prescribing practitioner or clinical pharmacist (such as, prescriptions, OTCs, herbal therapies and supplements) documented in the medical
1159F Medication list documented in medical record
1158F Advance care planning discussion documented in the medical record
1157F Advance care plan or similar legal document present in the medical record
1126F Pain severity quantified; no pain present
1125F Pain severity quantified; pain present
1111F Discharge medications reconciled with the current medication list in outpatient medical record
0503F Postpartum care visit