Feb. 25, 2021
Using the proper Procedural Terminology (CPT®) Category II codes when filing claims can help streamline your administrative processes and ensure gaps in care are closed.
Why it matters: CPT II codes are tracked for certain performance measures, including Healthcare Effectiveness Data and Information Set (HEDIS®) measures from the National Committee for Quality Assurance (NCQA). We use these measures to monitor and improve the quality of care our members receive.
How CPT II Codes Can Help: CPT II codes are more specific than CPT I codes. When submitted for services performed during office, lab or facility visits, CPT II codes can help:
- Provide more accurate medical data and decrease requests for members’ records for review
- Identify and close gaps in care more accurately and quickly; this drives HEDIS measures and quality improvement initiatives
- Track member screenings to help you monitor care and avoid sending unnecessary reminders
How to Submit CPT II Codes: CPT II codes may be submitted on claims with other applicable codes. The list of CPT II codes is updated annually according to HEDIS specifications published by NCQA. See our Claims and Eligibility webpage for claims filing tips.
Here are examples of 2021 measurement year HEDIS measures and applicable codes.
CPT II Coding Quick Reference |
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|---|---|---|
HEDIS Measure |
Description |
Applicable Codes |
Members ages 18-85 with a diagnosis of hypertension (HTN) and BP adequately controlled at 139/89 mmHg or less during the measurement year
|
Hypertension Diagnosis ICD-10-CM: I10, I11.9, I12.9, I13.10 (Essential Hypertension) Remote BP Monitoring CPT: 93784, 93788, 93790, 99091 |
|
Members ages 18-75 diagnosed with diabetes who have documentation in their medical record indicating the date and result of a Hemoglobin A1c test in the measurement year
|
HbA1c level less than 7.0 ICD-10-CM: E10.10-E13.9, O24.011-O24.33, O24.811-O24.83 HbA1c level Between 7.0–7.9 ICD-10-CM: E10.9, E10.10-E13.9, O24.011-O24.33, O24.811-O24.83 |
|
Pregnant members who delivered live births on or between Oct. 8 of the year prior to the measurement year and Oct. 7 of the measurement year and received a prenatal care visit in the first trimester, on or before the enrollment start date or within 42 days of enrollment in the health plan. |
Prenatal Visits ICD-10-CM: Use appropriate code from “O” family; Z03.71-Z03.75, Z03.79, Z34.00-Z34.03, Z34.80-Z34.83, Z34.90-Z34.93, Z36 |
CPT copyright 2020 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.
HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
The material presented here is for informational/educational purposes only, is not intended to be medical advice or a definitive source for coding claims and is not a substitute for the independent medical judgment of a physician or other health care provider. Health care providers are encouraged to exercise their own independent medical judgment based upon their evaluation of their patients’ conditions and all available information, and to submit claims using the most appropriate code(s) based upon the medical record documentation and coding guidelines and reference materials. References to other third-party sources or organizations are not a representation, warranty or endorsement of such organization. Any questions regarding those organizations should be addressed to them directly. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.