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ALL MEDICAL CODES IN CATEGORY Category II Codes > Patient History
2025 CPT Category II code 1158F
Documents an advance care planning discussion in the medical record.
2025 CPT code 1183F
Neuropsychiatric symptoms, absent.
2025 CPT code 1030F
Influenza immunization status assessed.
2025 CPT code 1153F
Documents advanced disease diagnosis where comfort is not the primary goal of care.
2025 CPT code 1134F
Episode of back pain lasting 6 weeks or less (BkP).
2025 CPT code 1159F
Medication list documented in the medical record.
2025 CPT code 1008F
Assessment of gastrointestinal and renal risk factors in patients using prescribed or OTC NSAIDs.
2025 CPT code 1010F
Assessment of angina severity in patients with coronary artery disease (CAD) based on their response to activity.
2025 CPT code 1011F
This CPT code indicates the presence of angina in a patient with coronary artery disease (CAD).
2025 CPT code 1004F
Assessment of clinical symptoms indicating excess fluid volume.
2025 CPT code 1055F
Assessment of a patient's visual functional status.
2025 CPT code 1036F
Identifies a patient 18 years or older as a current tobacco non-user.
2025 CPT code 1111F
Discharge medications are reconciled with the current medication list in the outpatient medical record.
2025 CPT code 1066F
Ischemic stroke with symptom onset ≥3 hours before arrival.
2025 CPT code 1126F
Pain severity quantified; no pain present.
2025 CPT code 1125F
Pain severity quantified; pain present.
2025 CPT code 1504F
This Category II CPT code tracks patient respiratory insufficiency due to Amyotrophic Lateral Sclerosis (ALS).
2025 CPT code 1032F
Identifies a patient who is a current tobacco smoker or is currently exposed to secondhand smoke, specifically relevant for asthma management.
2025 CPT code 1039F
Intermittent asthma diagnosis.
2025 CPT code 1502F
Patient queried about pain and pain interference with function using a valid and reliable instrument (DSP).
2025 CPT code 1019F
Dyspnea assessed, present (COPD).
2025 CPT code 1461F
No qualifying cardiac event/diagnosis in previous 12 months (CAD).
2025 CPT code 1493F
Dementia severity classified, severe (DEM)
2025 CPT code 1180F
Assessment of all specified thromboembolic risk factors in atrial fibrillation (AFIB).
2025 CPT code 1200F
Documents seizure type(s) and current seizure frequency(ies) for epilepsy (EPI).
2025 CPT code 1031F
Assessment of smoking status and secondhand smoke exposure at home for asthma patients.
2025 CPT code 1022F
Assessment of pneumococcus immunization status in patients with community-acquired pneumonia (CAP) or chronic obstructive pulmonary disease (COPD).
2025 CPT code 1118F
Assessment of GERD symptoms in patients after 12 months of therapy.
2025 CPT code 1500F
Documentation of symptoms and signs consistent with distal symmetric polyneuropathy (DSP).
2025 CPT code 1071F
Assessment of alarm symptoms (involuntary weight loss, dysphagia, or gastrointestinal bleeding); one or more present (GERD).
2025 CPT code 1121F
Documents subsequent evaluation for a condition relevant to a program measure; supplemental tracking code.
2025 CPT code 1127F
New episode for a condition.
2025 CPT code 1503F
Patient queried about symptoms of respiratory insufficiency (ALS).
2025 CPT code 1026F
Assessment of co-morbid conditions, such as malignancy, liver disease, heart failure, and others.
2025 CPT code 1128F
This CPT Category II code tracks subsequent episodes of a condition for performance measurement purposes.It is not used for reimbursement.
2025 CPT code 1182F
Documents the presence of one or more neuropsychiatric symptoms in a patient with dementia (DEM).
2025 CPT code 1050F
Documents the obtaining of a patient history regarding new or changing moles.
2025 CPT code 1123F
Documents advance care planning discussions where an advance care plan or surrogate decision-maker was recorded in the medical record.
2025 CPT code 1135F
Episode of back pain lasting longer than 6 weeks (BkP)
2025 CPT code 1136F
Episode of back pain lasting 12 weeks or less (BkP).
2025 CPT code 1130F
Back pain and function assessed, including pain assessment, functional status, patient history (including "red flags"), prior treatment assessment, and employment status (BkP).
2025 CPT code 1065F
Ischemic stroke symptom onset of less than 3 hours prior to arrival (STR).
2025 CPT code 1494F
Cognition assessed and reviewed (DEM)
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 1157F
Indicates the presence of an advance care plan or similar legal document in the patient's medical record.
2025 CPT code 1205F
Documents the etiology of epilepsy or epilepsy syndrome(s) reviewed.
2025 CPT code 1061F
Documentation of absence of permanent, persistent, and paroxysmal atrial fibrillation (STR).
2025 CPT code 1015F
Assessment of chronic obstructive pulmonary disease (COPD) symptoms, including dyspnea, cough/sputum, or wheezing; or completion of a respiratory symptom assessment tool for COPD.
2025 CPT code 1002F
Assessment of anginal symptoms and the level of physical activity they affect.
2025 CPT code 1119F
Initial evaluation for a condition related to a program measure (Hepatitis C, Epilepsy, or Distal Symmetric Polyneuropathy).
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