As we published in our last newsletter, CPT Category II Codes are supplemental tracking codes that are meant to facilitate data collection about quality of care and decrease the need for record abstraction and chart reviews.  For example, let's say your practice is trying to track the use of beta-blocker therapy and you don't have an electronic medical record system. Reporting Category II code 0007F, "Beta-blocker therapy, prescribed," will allow you to do this through your billing software rather than through chart reviews. This will greatly reduce the administrative burden on your office. In addition, these codes allow health plans to determine numerator compliance through analysis of claims submitted by your office reducing the need for chart reviews for HEDIS measures.

Calculating performance measurement requires a numerator and a denominator. The denominator is the total number of patients with or visits addressing the specified condition (i.e., all of your patients with diabetes). The numerator is the number of those patients/visits that meet the performance being measured (i.e., the number of your patients with diabetes who have had an HbA1c test in the last 6 months). Category II codes are used to determine the numerator (i.e., those with a particular test result or a certain documented history). Category II exclusion modifiers are used to determine the denominator, along with ICD-9 diagnosis codes and CPT Category 1 codes. Based on the CPT 2007 Manual the exclusion modifiers “may be used to indicate that a service specified by a performance measure was considered but, due to either medical, patient, or systems reason(s) documented in the medical record, the service was not provided.

Claims-Based Reporting Principles

Reporting a measurement result is done using the claims form.  The claims based reporting is done by completing  the paper-based 1500 claim form or  the equivalent electronic transaction claim. 

The following principles apply to the reporting of HEDIS measures:

• The CPT Category II code must be reported on the same claim form as the payment codes, usually ICD-9-CM and CPT Category I codes, which supply the denominator.
• CPT Category II codes must be submitted with a line item charge of zero dollars ($0.00) at the time the associated covered service is performed.
• The submitted charge field cannot be blank.
• The line item charge should be $0.00.
• CPT Category II line items will be denied for payment, but are then passed through the claims processing system for P4P analysis.
• Multiple CPT Category II codes for multiple measures that are applicable to a patient visit can be reported on the same claim.

Category II codes have their own section in the CPT code book and are cross-referenced to the measures associated with each in Appendix H. The AMA publishes Category II codes twice a year: on Jan. 1 and July 1. For the most current listing, visit http://www.ama-assn.org/go/cpt.

HEDIS 2008 specifications include the following CPT Category II Codes:

CPT® is a registered trademark of the American Medical Association.