March 2021
CPT® Category II Codes Can Help Close Care Gaps
Using the proper Current Procedural Terminology (CPT) Category II codes when filing claims may help you streamline your administrative processes and close gaps in care.
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 help monitor and improve the quality of care our members receive.
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
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.
CPT II Coding – Examples for Quick Reference Purposes
Listed below are examples of 2021 measurement year HEDIS measures and applicable codes.
| 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 A diagnosis of Essential Hypertension and last blood pressure reading in 2021 should be documented in the medical record. |
Hypertension diagnosis:
|
||||
| Remote BP monitoring: CPT – 93784, 93788, 93790, 99091 |
|||||
| Comprehensive Diabetes Care (CDC) | 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. Last A1c result in 2021 should be documented in the medical record. |
HbA1c level less than 7.0:
|
|||
HbA1c level between 7.0 and 7.9:
|
|||||
| Prenatal and Postpartum Care (PPC) | Pregnant members who delivered live births on or between October 8 of the year prior to the measurement year and October 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:
|
|||
CPT copyright 2020 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.
HEDIS is a registered trademark of 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.