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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 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).

2025 CPT code 3293F

ABO and Rh blood typing documented as performed.

2025 CPT code 3093F

Documentation of new diagnosis of initial or recurrent episode of major depressive disorder (MDD).

2025 CPT code 4553F

Patient offered assistance in planning for end of life issues (ALS).

2025 CPT code 1505F

Patient does not have respiratory insufficiency (ALS).

2025 CPT code 1040F

DSM-5 criteria for major depressive disorder documented at the initial evaluation.

2025 CPT code 3042F

Functional expiratory volume (FEV1) >= 40% of predicted value (COPD).

2025 CPT code 3266F

Documents Hepatitis C genotype testing performed before starting antiviral treatment for Hepatitis C.

2025 CPT code 2014F

Mental status assessed.

2025 CPT code 4558F

Patient received at least 2 prophylactic pharmacologic anti-emetic agents of different classes preoperatively and intraoperatively.

2025 CPT code 2060F

Patient interviewed directly on or before date of diagnosis of major depressive disorder (MDD ADOL).

2025 CPT code 3292F

HIV testing ordered or documented and reviewed during the first or second prenatal visit.

2025 CPT code 3323F

Clinical tumor, node, and metastases (TNM) staging is documented and reviewed before surgery for lung or esophageal cancer.

2025 CPT code 2028F

Foot examination performed, including visual inspection, sensory exam with monofilament, and pulse exam. Report when any of the three components are completed.

2025 CPT code 3100F

Carotid imaging study report that includes direct or indirect reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement.

2025 CPT code 3215F

Patient has documented immunity to Hepatitis A.

2025 CPT code 7025F

Patient information entered into a reminder system with a target due date for the next mammogram (RAD).

2025 CPT code 1220F

Patient screened for depression (SUD).

2025 CPT code 3066F

Documentation of treatment for nephropathy (e.g., patient receiving dialysis, being treated for ESRD, CRF, ARF, or renal insufficiency, any visit to a nephrologist).

2025 CPT code 3037F

Oxygen saturation greater than 88% or PaO2 greater than 55 mm Hg (COPD).

2025 CPT code 3055F

Left ventricular ejection fraction (LVEF) less than or equal to 35% (HF).

2025 CPT code 4328F

Patient (or caregiver) queried about sleep disturbances (Prkns).

2025 CPT code 3270F

Bone scan not performed prior to initiation of treatment nor at any time since diagnosis of prostate cancer.

2025 CPT code 3271F

Indicates low risk of recurrence for prostate cancer (PRCA).

2025 CPT code 3294F

Documents Group B Streptococcus (GBS) screening performed at 35-37 weeks gestation.

2025 CPT code 2035F

Documents the assessment of tympanic membrane mobility using pneumatic otoscopy or tympanometry in patients diagnosed with otitis media with effusion (OME).

2025 CPT code 3301F

Documents the review and classification of cancer as metastatic in a patient 18 years or older, using the AJCC system.

2025 CPT code 2050F

Documents wound characteristics including size, nature of wound base tissue, and amount of drainage before debridement (CWC).

2025 CPT code 4340F

Counseling for women of childbearing potential with epilepsy.

2025 CPT code 7020F

Mammogram assessment category (e.g., MQSA, BI-RADS, or FDA-approved equivalent) entered into a database to analyze the abnormal interpretation (recall) rate.

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.