CPT Category II Codes Can Help Close Care Gaps

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

  • A diagnosis of Essential Hypertension should be documented in the medical record.
  • Last blood pressure reading in 2021

Hypertension Diagnosis
ICD-10-CM: I10, I11.9, I12.9, I13.10 (Essential Hypertension)
3074F (systolic <130 mmHg)
3075F (systolic =130-139 mmHg) 3077F (systolic >140 mmHg)
3078F (diastolic <80 mmHg)
3079F (diastolic =80-89 mmHg)
3080F (diastolic > 90 mmHg)

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

HbA1c level less than 7.0
ICD-10-CM: E10.10-E13.9, O24.011-O24.33, O24.811-O24.83
CPT II: 3044F

HbA1c level Between 7.0–7.9
ICD-10-CM: E10.9, E10.10-E13.9, O24.011-O24.33, O24.811-O24.83
CPT II: 3051F

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
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 II: 0500F, 0501F, 0502F

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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