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ALL MEDICAL CODES IN CATEGORY Category II Codes

2025 CPT Category II code 1158F

Documents an advance care planning discussion in the medical record.

2025 CPT code 1451F

Symptoms demonstrated clinically important deterioration since last assessment (HF).

2025 CPT code 3344F

Documents a mammogram assessment categorized as "suspicious".

2025 CPT code 3354F

Clinically significant depressive symptoms as categorized by using a standardized depression screening/assessment tool.

2025 CPT code 1183F

Neuropsychiatric symptoms, absent.

2025 CPT code 3155F

Cytogenetic testing performed on bone marrow at the time of diagnosis or prior to initiating treatment for myelodysplastic syndrome (MDS) or acute leukemia.

2025 CPT code 3017F

Documentation and review of colorectal cancer screening results, including fecal occult blood testing annually, flexible sigmoidoscopy every 5 years, double-contrast barium enema every 5 years, or colonoscopy every 10 years.

2025 CPT code 1400F

Parkinson's disease diagnosis reviewed.

2025 CPT code 3650F

Electroencephalogram (EEG) ordered, reviewed, or requested.

2025 CPT code 3331F

Imaging study not ordered.

2025 CPT code 3250F

Specimen site other than anatomic location of primary tumor.

2025 CPT code 3052F

Most recent hemoglobin A1c (HbA1c) level greater than or equal to 8.0% and less than or equal to 9.0%.

2025 CPT code 3074F

Most recent systolic blood pressure less than 130 mm Hg.

2025 CPT code 3120F

12-Lead ECG Performed. This code tracks whether a 12-lead electrocardiogram (ECG) was performed.

2025 CPT code 1038F

This code documents the presence of persistent asthma (mild, moderate, or severe).

2025 CPT code 3130F

Upper gastrointestinal endoscopy performed for GERD.

2025 CPT code 3096F

Order for a central dual-energy X-ray absorptiometry (DXA) scan.

2025 CPT code 3452F

Dyspnea not screened (Pall Cr).

2025 CPT code 3386F

Documents stage II colon cancer in patients 18 years and older, covering stages IIA, IIB, and IIC, characterized by tumor invasion into deeper colon layers.

2025 CPT code 3378F

AJCC Breast Cancer Stage III documented (ONC).

2025 CPT code 3455F

Tuberculosis (TB) screening performed and results interpreted within six months prior to initiation of first-time biologic disease modifying anti-rheumatic drug (DMARD) therapy for rheumatoid arthritis (RA).

2025 CPT code 1070F

Alarm symptoms (involuntary weight loss, dysphagia, or gastrointestinal bleeding) assessed; none present (GERD).

2025 CPT code 1003F

Level of activity assessed. This code is used for performance measurement and is not a substitute for Category I codes.

2025 CPT code 3370F

AJCC Breast Cancer Stage 0 documented (ONC).

2025 CPT code 4300F

Patient receiving warfarin therapy for nonvalvular atrial fibrillation or atrial flutter (AFIB).

2025 CPT code 3111F

CT or MRI of the brain performed in the hospital within 24 hours of arrival or in an outpatient imaging center, to confirm initial diagnosis of stroke, TIA, or intracranial hemorrhage (STR).

2025 CPT code 4350F

Counseling provided on symptom management, end of life decisions, and palliation.

2025 CPT code 4551F

Nutritionalsupport offered (ALS)

2025 CPT code 3382F

Documentation of AJCC stage 0 colon cancer in a patient 18 years or older.

2025 CPT code 4196F

Documents that the patient is not receiving first-time biologic disease-modifying anti-rheumatic drug (DMARD) therapy for rheumatoid arthritis (RA).

2025 CPT code 4181F

Conformal radiation therapy received.

2025 CPT code 3324F

MRI or CT scan ordered, reviewed, or requested.

2025 CPT code 2019F

Dilated macular exam performed, documenting macular thickening, hemorrhage, and macular degeneration severity.

2025 CPT code 4526F

Neuropsychiatric intervention received for dementia (DEM).

2025 CPT code 4326F

Patient (or caregiver) queried about symptoms of autonomic dysfunction (Parkinson's disease).

2025 CPT code 4169F

Tracks whether a patient is receiving care in the ICU, mechanical ventilation, or both.

2025 CPT code 4560F

Anesthesia technique did not involve general or neuraxial anesthesia.

2025 CPT code 4073F

Oral antiplatelet therapy prescribed at discharge (for performance measurement).

2025 CPT code 5100F

Communicating potential fracture risk to the referring physician within 24 hours of completing a nuclear medicine imaging study.

2025 CPT code 3019F

Planned assessment of left ventricular ejection fraction (LVEF) post-discharge for heart failure (HF).

2025 CPT code 4070F

Deep vein thrombosis (DVT) prophylaxis received by the end of hospital day 2.

2025 CPT code 1160F

Review of all medications (prescriptions, OTCs, herbal therapies, supplements) documented in the medical record by a prescribing practitioner or clinical pharmacist.

2025 CPT code 3351F

Negative screen for depressive symptoms using a standardized depression screening/assessment tool.

2025 CPT code 1157F

Indicates the presence of an advance care plan or similar legal document in the patient's medical record.

2025 CPT code 4324F

Patient (or caregiver) queried about Parkinson's disease medication-related motor complications.

2025 CPT code 4510F

Completion of prior cardiac rehabilitation for a qualifying cardiac event (CAD).

2025 CPT code 4552F

Patient offered referral to a speech-language pathologist (ALS).

2025 CPT code 3763F

Patient is not dysarthric (ALS).

2025 CPT code 4554F

Patient received inhalational anesthetic agent.

2025 CPT code 9005F

Asymptomatic carotid stenosis; no history of transient ischemic attack or stroke in carotid or vertebrobasilar territory.