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ALL MEDICAL CODES IN CATEGORY Patient History

2025 CPT Category II code 1158F

Documents an advance care planning discussion in the medical record.

2025 CPT code 1151F

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

2025 CPT code 1152F

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

2025 CPT code 1040F

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

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 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 1220F

Patient screened for depression (SUD).

2025 CPT code 1038F

This code documents the presence of persistent asthma (mild, moderate, or severe).

2025 CPT code 1070F

Alarm symptoms (involuntary weight loss, dysphagia, or gastrointestinal bleeding) assessed; none present (GERD).

2025 CPT code 1181F

Neuropsychiatric symptoms assessed and results reviewed.

2025 CPT code 1150F

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

2025 CPT code 1461F

No qualifying cardiac event/diagnosis in previous 12 months (CAD).

2025 CPT code 1490F

Dementia severity classified, mild (DEM).

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 1491F

Dementia severity classified, moderate (DEM)

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 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 HCPCS code G8560

Reports a patient's history of ear discharge within the past 90 days.

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 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 1100F

Patient screened for future fall risk; documentation of two or more falls in the past year or any fall with injury in the past year.

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 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 1127F

New episode for a condition.

2025 CPT code 1116F

Assessment of auricular or periauricular pain.

2025 CPT code 1175F

Assessment of functional status in dementia patients and review of results.

2025 CPT code 1182F

Documents the presence of one or more neuropsychiatric symptoms in a patient with dementia (DEM).

2025 CPT code 1090F

Assesses the presence or absence of urinary incontinence in women aged 65 and over.

2025 CPT code 1451F

Symptoms demonstrated clinically important deterioration since last assessment (HF).

2025 CPT code 1183F

Neuropsychiatric symptoms, absent.

2025 CPT code 1005F

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

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 1205F

Documents the etiology of epilepsy or epilepsy syndrome(s) reviewed.

2025 CPT code 1008F

Assessment of gastrointestinal and renal risk factors in patients using prescribed or OTC NSAIDs.

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 1119F

Initial evaluation for a condition related to a program measure (Hepatitis C, Epilepsy, or Distal Symmetric Polyneuropathy).

2025 CPT code 1033F

This Category II CPT code indicates that a patient with asthma is a current non-smoker with no exposure to secondhand smoke, thus eliminating the need for tobacco cessation intervention.