Description:
This policy is to provide guidance on the use of Current Procedural Terminology (CPT) Category II Codes for Healthcare Effectiveness Data and Information Set (HEDIS) measure and quality improvements.
Guidance:
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 and reduce medical record requests to capture these measurements.
HEDIS Code and Measure
|
When to Report
|
CPT II Code
|
ICD-10 Diagnosis Code(s)
|
PPC - Prenatal and Postpartum Care
|
Report for Prenatal and 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
|
CDC - Comprehensive Diabetes Care-HbA1c level less than 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
|
Date of Service (DOS) 12/31/2019 and Prior –
3045F
DOS 01/01/2020 and After –
3051F
3052F
|
E10.9, E10.10-E13.9, O24.011-
O24.33, O24.811-O24.83
|
FUA - Follow up after discharge from ED for alcohol and other drug dependence
|
For use after discharge from emergency department (ED) only
|
3016F
|
Z71.41, Z71.89
|
CBP - Controlling Blood Pressure
|
A diagnosis of Essential Hypertension should be documented in the medical record
|
3074F, 3075F, 3077F, 3078F and 3079F
|
I10, I11.9, I12.9, I13.10
|