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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 4559F

At least one body temperature measurement equal to or greater than 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time.

2025 CPT code 9001F

Documents an aortic aneurysm less than 5.0 cm on CT.

2025 CPT code 4062F

Documents patient referral for psychotherapy for Major Depressive Disorder (MDD), including adolescents (MDD ADOL).

2025 CPT code 3372F

AJCC Breast Cancer Stage I: T1mic, T1a, or T1b (tumor size ≤ 1 cm) documented (ONC).

2025 CPT code 2023F

Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy (DM).

2025 CPT code 1501F

Not initial evaluation for condition (DSP)

2025 CPT code 1460F

Qualifying cardiac event/diagnosis in previous 12 months (CAD).

2025 CPT code 1450F

Symptoms improved or remained consistent with treatment goals since last assessment (HF).

2025 CPT code 1007F

Use of anti-inflammatory or analgesic over-the-counter (OTC) medications for symptom relief assessed.

2025 CPT code 1091F

Urinary incontinence characterized (e.g., frequency, volume, timing, type of symptoms, how bothersome).

2025 CPT code 1005F

Assessment of asthma symptoms, including documentation of symptom frequency or patient completion of an asthma assessment tool.

2025 CPT code 3022F

Left ventricular ejection fraction (LVEF) greater than or equal to 40% or documentation as normal or mildly depressed left ventricular systolic function.

2025 CPT code 3345F

Mammogram assessment category of "highly suggestive of malignancy," documented.

2025 CPT code 3352F

No significant depressive symptoms as categorized by using a standardized depression assessment tool.

2025 CPT code 3341F

Documents a negative mammogram assessment, indicating no signs of cancer were found.

2025 CPT code 3330F

Imaging study ordered.

2025 CPT code 3342F

Mammogram assessment category of "benign," documented.

2025 CPT code 3077F

Documents a patient's most recent systolic blood pressure as greater than or equal to 140 mm Hg.

2025 CPT code 3073F

Documentation of pre-surgical (cataract) axial length, corneal power measurement, and IOL power calculation method within 12 months before surgery.

2025 CPT code 3082F

Kt/V less than 1.2 (Clearance of urea [Kt]/volume [V]) (ESRD, P-ESRD).

2025 CPT code 3048F

Most recent LDL-C level less than 100 mg/dL.

2025 CPT code 3075F

Most recent systolic blood pressure 130-139 mm Hg.

2025 CPT code 3117F

Heart failure disease-specific structured assessment tool completed.

2025 CPT code 3083F

Kt/V equal to or greater than 1.2 and less than 1.7 (Clearance of urea [Kt]/volume [V]).

2025 CPT code 1124F

Advance care planning discussed and documented, but the patient declined or was unable to name a surrogate decision-maker or provide an advance care plan.

2025 CPT code 1150F

Documentation that a patient has a substantial risk of death within 1 year.

2025 CPT code 4187F

Disease-modifying antirheumatic drug (DMARD) therapy prescribed or dispensed; RA

2025 CPT code 1490F

Dementia severity classified, mild (DEM).

2025 CPT code 3216F

Patient has documented immunity to Hepatitis B.

2025 CPT code 6101F

Safety counseling for dementia provided.

2025 CPT code 3230F

Documents that a hearing test was performed within 6 months prior to tympanostomy tube insertion (OME).

2025 CPT code 4176F

Counseling about the value of protection from UV light and lack of proven efficacy of nutritional supplements in preventing or slowing the progression of cataracts, provided to the patient and/or caregiver(s).

2025 CPT code 3269F

Bonescan performed prior to initiation of treatment or at any time since diagnosis of prostate cancer.

2025 CPT code 5015F

Documents communication about a fracture and the need for osteoporosis testing or treatment.

2025 CPT code 5005F

Patient counseled on self-examination for new or changing moles.

2025 CPT code 9002F

Aortic aneurysm 5.0 - 5.4 cm maximum diameter on centerline formatted CT or minor diameter on axial formatted CT (NMA-No Measure Associated).

2025 CPT code 4555F

Patient did not receive inhalational anesthetic agent.

2025 CPT code 1101F

Patient screened for future fall risk; documentation of no falls in the past year or only one fall without injury.

2025 CPT code 2000F

Blood pressure measured (CKD)(DM)

2025 CPT code 1018F

Dyspnea assessed, not present (COPD).

2025 CPT code 1006F

Assessment of osteoarthritis symptoms and functional status, possibly using standardized scales like the SF-36 or AAOS Hip & Knee Questionnaire.Report this code when osteoarthritis is addressed during the patient encounter.

2025 CPT code 3023F

Spirometry results documented and reviewed for a patient with COPD.

2025 CPT code 4540F

Disease-modifying pharmacotherapy discussed (ALS).

2025 CPT code 9007F

Documentation of carotid artery stenosis evidenced by ipsilateral TIA or stroke >120 days prior, or prior contralateral TIA/stroke.

2025 CPT code 3078F

Most recent diastolic blood pressure less than 80 mm Hg (HTN, CKD, CAD, DM).

2025 CPT code 3343F

Documents a mammogram assessment categorized as "probably benign".

2025 CPT code 4481F

Patient receiving ACE inhibitor/ARB therapy and beta-blocker therapy for less than 3 months or patient not receiving ACE inhibitor/ARB therapy and beta-blocker therapy (HF).

2025 CPT code 1151F

Documentation that a patient does not have a substantial risk of death within one year.

2025 CPT code 3328F

Performance status documented and reviewed within 2 weeks prior to surgery (Lung/Esop Cx).