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This CPT Category II code tracks patients exhibiting three or more risk factors for post-operative nausea and vomiting (PONV).
2025 CPT code 4193F
Patient receiving <10 mg daily prednisone (or equivalent), or RA activity is worsening, or glucocorticoid use is for less than 6 months (RA)
2025 CPT code 4541F
Patient offered treatment for pseudobulbar affect, sialorrhea, or ALS-related symptoms.
2025 CPT code 4157F
Documentation of prior Hepatitis B vaccine series.
2025 CPT code 4325F
Review of medical and surgical treatment options with patient (or caregiver) for Parkinson's disease.
2025 CPT code 4063F
Antidepressant pharmacotherapy considered and not prescribed for Major Depressive Disorder in Adolescents (MDD ADOL).
2025 CPT code 4266F
Use of wet to dry dressings neither prescribed nor recommended (CWC).
2025 CPT code 4077F
Documents that the administration of tissue plasminogen activator (t-PA) was considered.
2025 CPT code 4268F
Patient education regarding the need for long-term compression therapy, including interval replacement of compression stockings.
2025 CPT code 4090F
Patient receiving erythropoietin therapy (HEM)
2025 CPT code 4260F
Wound surface culture technique used (CWC).
2025 CPT code 4052F
Hemodialysis via functioning arteriovenous (AV) fistula (ESRD).
2025 CPT code 4290F
Patient screened for injection drug use (HIV).
2025 CPT code 4526F
Neuropsychiatric intervention received for dementia (DEM).
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 4064F
Antidepressant pharmacotherapy prescribed for major depressive disorder (MDD) in adults or adolescents (MDD ADOL).
2025 CPT code 4070F
Deep vein thrombosis (DVT) prophylaxis received by the end of hospital day 2.
2025 CPT code 4324F
Patient (or caregiver) queried about Parkinson's disease medication-related motor complications.
2025 CPT code 4552F
Patient offered referral to a speech-language pathologist (ALS).
2025 CPT code 4191F
Appropriate anticonvulsant therapeutic monitoring test ordered or performed.
2025 CPT code 4554F
Patient received inhalational anesthetic agent.
2025 CPT code 4557F
Patient does not exhibit 3 or more risk factors for post-operative nausea and vomiting.
2025 CPT code 4136F
Systemic corticosteroids not prescribed for otitis media with effusion (OME).
2025 CPT code 4172F
Patient not receiving erythropoiesis-stimulating agents (ESA) therapy (CKD)
2025 CPT code 4221F
Diuretic medication therapy for six months or more.
2025 CPT code 4004F
Patient screened for tobacco use and received tobacco cessation intervention (counseling, pharmacotherapy, or both), if identified as a tobacco user.
2025 CPT code 4100F
Intravenous bisphosphonate therapy ordered or received.
2025 CPT code 4267F
Compression therapy prescribed (CWC).
2025 CPT code 4134F
Antihistamines or decongestants neither prescribed nor recommended for otitis media with effusion (OME).
2025 CPT code 4017F
Gastrointestinal prophylaxis for NSAID use prescribed.
2025 CPT code 4279F
Pneumocystis jiroveci pneumonia prophylaxis prescribed for HIV patients.
2025 CPT code 4220F
Digoxin medication therapy for 6 months or more.
2025 CPT code 4132F
Systemic antimicrobial therapy not prescribed for acute otitis externa (AOE).
2025 CPT code 4131F
Systemic antimicrobial therapy prescribed for acute otitis externa (AOE).
2025 CPT code 4025F
Inhaled bronchodilator prescribed for COPD.
2025 CPT code 4075F
Anticoagulant therapy prescribed at discharge.
2025 CPT code 4175F
Best-corrected visual acuity of 20/40 or better (distance or near) achieved within 90 days following cataract surgery.
2025 CPT code 4066F
Electroconvulsive therapy (ECT) provided (MDD).
2025 CPT code 4158F
Patient counseled about risks of alcohol use (HEP-C).
2025 CPT code 4180F
Adjuvant chemotherapy referred, prescribed, or previously received for Stage III colon cancer.
2025 CPT code 4069F
Records that venous thromboembolism (VTE) prophylaxis was administered to a patient with inflammatory bowel disease (IBD).
2025 CPT code 4054F
Hemodialysis via catheter (ESRD).
2025 CPT code 4168F
Patient receiving care in the intensive care unit (ICU) and receiving mechanical ventilation, 24 hours or less.
2025 CPT code 4164F
Adjuvant hormonal therapy (GnRH agonist or antagonist) prescribed/administered for prostate cancer, in combination with external beam radiotherapy.
2025 CPT code 4255F
Documents general or neuraxial anesthesia lasting 60 minutes or more, as per anesthesia records.
2025 CPT code 4210F
Tracking code for angiotensin-converting enzyme (ACE) or angiotensin receptor blockers (ARB) medication therapy lasting 6 months or more.
2025 CPT code 4165F
This CPT Category II code tracks the receipt of 3-dimensional conformal radiotherapy (3D-CRT) or intensity-modulated radiation therapy (IMRT).
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