Feb. 26, 2021
Using the proper Current 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. Category II CPT codes are reviewed and revised annually by the CPT/Health Care Professional Advisory Committee with input from NCQA for the HEDIS measures. 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 | ||
|---|---|---|
| HEDIS Measure | Description | Applicable Codes |
| Controlling High Blood Pressure (CBP) | 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 |
| 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
|
HbA1c level less than 7.0 |
HbA1c level Between 7.0–7.9 |
||
| Prenatal and Postpartum Care (PPC) | 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 |
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).
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Blue Cross and Blue Shield of Montana, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association