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ALL MEDICAL CODES IN CATEGORY Category II

2025 CPT code 1152F

Documentation of advanced disease diagnosis, goals of care prioritize comfort.

2025 CPT code 1137F

Episode of back pain lasting longer than 12 weeks (BkP).

2025 CPT code 1052F

Type, anatomic location, and activity all assessed (IBD).

2025 CPT code 1000F

Tobacco use assessed.

2025 CPT code 1220F

Patient screened for depression (SUD).

2025 CPT code 0509F

Documents the presence of a documented plan of care for urinary incontinence.

2025 CPT code 5200F

Consideration of referral for a neurological evaluation of appropriateness for surgical therapy for intractable epilepsy within the past 3 years.

2025 CPT code 1110F

Patient discharged from an inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility) within the last 60 days.

2025 CPT code 2021F

Dilated macular or fundus exam performed, including documentation of the presence or absence of macular edema and level of severity of retinopathy.

2025 CPT code 2015F

Assessment of asthma impairment.

2025 CPT code 4293F

Patient screened for high-risk sexual behavior (HIV).

2025 CPT code 4181F

Conformal radiation therapy received.

2025 CPT code 3324F

MRI or CT scan ordered, reviewed, or requested.

2025 CPT code 2024F

Seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist, documented and reviewed; with evidence of retinopathy.

2025 CPT code 3020F

Left ventricular function (LVF) assessment documented in the medical record, including quantitative or qualitative assessment results.

2025 CPT code 3267F

This CPT II code indicates that a pathology report for a radical prostatectomy includes pT category, pN category, Gleason score, and margin status.

2025 CPT code 3272F

Intermediate risk of recurrence, prostate cancer (PRCA).

2025 CPT code 4067F

Documentation of patient referral for electroconvulsive therapy (ECT) for major depressive disorder (MDD).

2025 CPT code 3350F

Mammogram assessment categorized as "known biopsy-proven malignancy," documented (RAD).

2025 CPT code 0582F

Patient not transferred directly from anesthetizing location to critical care unit.

2025 CPT code 0513F

Elevated blood pressure plan of care documented (CKD).

2025 CPT code 4274F

Influenza immunization administered or previously received for patients with HIV or ESRD receiving dialysis.

2025 CPT code 3514F

Documents that a Hepatitis C screening was performed.

2025 CPT code 3476F

Disease prognosis for rheumatoid arthritis assessed, good prognosis documented.

2025 CPT code 1012F

This code documents the absence of angina in a patient with coronary artery disease (CAD).

2025 CPT code 2040F

Physical examination performed on the date of the initial visit for low back pain, in accordance with specifications.

2025 CPT code 3330F

Imaging study ordered.

2025 CPT code 3117F

Heart failure disease-specific structured assessment tool completed.

2025 CPT code 4562F

Patient does not have a coronary artery stent (Peri2).

2025 CPT code 5010F

Documents communication of dilated macular or fundus exam findings to the physician managing diabetes care.

2025 CPT code 4322F

Caregiver provided education and referral to additional resources for support, related to dementia.

2025 CPT code 3023F

Spirometry results documented and reviewed for a patient with COPD.

2025 CPT code 1491F

Dementia severity classified, moderate (DEM)

2025 CPT code 2026F

Eye imaging validation of 7-field stereoscopic retinal photos, with documented review and evidence of retinopathy.

2025 CPT code 2025F

Seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy (DM).

2025 CPT code 3284F

Indicates that intraocular pressure (IOP) has been reduced by at least 15% from the pre-intervention level.

2025 CPT code 0500F

Initial prenatal care visit; reported at the first prenatal encounter with an obstetrical provider.The date of the visit and the last menstrual period (LMP) must also be reported.

2025 CPT code 0521F

Documentation of a plan of care to address patient pain.

2025 CPT code 0540F

Documentation of a glucocorticoid management plan for a patient with rheumatoid arthritis (RA).

2025 CPT code 0501F

Documents prenatal flow sheet at the first prenatal visit, including vital signs, urine analysis, uterine size, fetal heart tones, and estimated delivery date.

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 3720F

Assessment of cognitive impairment or dysfunction.

2025 CPT code 3498F

Documents a patient's CD4+ cell percentage of 15% or higher, indicating a stronger immune system in individuals with HIV.

2025 CPT code 3700F

Assessment of psychiatric disorders or disturbances.

2025 CPT code 4042F

Documentation that prophylactic antibiotics were not administered within 4 hours prior to surgical incision or intraoperatively.

2025 CPT code 3570F

Final report for bone scintigraphy includes correlation with existing imaging studies (x-ray, MRI, CT) of the same anatomical region.

2025 CPT code 1123F

Documents advance care planning discussions where an advance care plan or surrogate decision-maker was recorded in the medical record.