This document provides coding and billing guidelines for the use of Current Procedural Terminology (CPT) Category II Codes for Healthcare Effectiveness Data and Information Set (HEDIS) measure and quality improvements.
Coding & Billing Guidelines
Blue Cross Blue Shield of North Dakota (BCBSND) encourages providers to submit a CPT Category II code to assist in tracking the delivery of quality care. The codes simplify how performance measures are reported and eliminate the need for BCBSND to request medical records to determine if HEDIS measures are met. Doctors and hospitals can use CPT Category II codes to report specific services that contribute to positive outcomes and high-quality care.
When CPT Category II codes are reported for specific services performed:
- It decreases BCBSND’s need to request a member’s chart notes.
- It allows BCBSND to identify and close gaps in care more quickly, which drives HEDIS measures.
- It provides access to more accurate medical data.
- It helps BCBSND support provider care plan through more targeted case management services.
The below grid lists the HEDIS measures and applicable Category II code and ICD-10 Diagnosis codes that may be billed to close the gap & reduce medical record requests to capture these measurements.
HEDIS Measurements
|
When to Report
|
CPT II Code
|
ICD-10 Code(s)
|
Prenatal & Postpartum Care
|
Report for Prenatal & subsequent care visits only
|
0500F, 0501F, 0502F
|
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
|
Comprehensive Diabetes Care
HbA1c level < 7.0
|
Diabetic members only
|
3044F
|
E10.10-E13.9, O24.011-O24.33, O24.811-O24.83 |
Comprehensive Diabetes Care
HbA1c level 7.0–9.0
|
Diabetic members only
|
DOS 12/31/2019 & Prior
3045F
DOS 01/01/2020 & After
3051F
3052F |
E10.9, E10.10-E13.9, O24.011-O24.33, O24.811-O24.83
|
Follow up after discharge from ED for alcohol & other drug dependence
|
For use after discharge from emergency department (ED) only
|
3016F
|
Z71.41, Z71.89
|
Controlling Blood Pressure
|
A diagnosis of Essential Hypertension should be documented in the medical record
|
3074F, 3075F, 3077F, 3078F, 3079F and 3080F
|
I10, I11.9, I12.9, I13.10
|
History
Date
|
Updates
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9/22/2021
|
Updated format
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3/11/2022
|
Added 3080F to CPT II Codes for Controlling Blood Pressure
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7/26/2022
|
Annual review completed.
|
7/24/2023
|
Annual review completed.
|
2/13/2024
|
Annual review completed. Changed “Revised Date:” to “Revision Effective Date:”
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