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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 1090F

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

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 1012F

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

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 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 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 1101F

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

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 1153F

Documents advanced disease diagnosis where comfort is not the primary goal of care.

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 1008F

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

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 1004F

Assessment of clinical symptoms indicating excess fluid volume.

2025 CPT code 1055F

Assessment of a patient's visual functional status.

2025 CPT code 1036F

Identifies a patient 18 years or older as a current tobacco non-user.

2025 CPT code 1111F

Discharge medications are reconciled with the current medication list in the outpatient medical record.

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 1125F

Pain severity quantified; pain present.

2025 CPT code 1504F

This Category II CPT code tracks patient respiratory insufficiency due to Amyotrophic Lateral Sclerosis (ALS).

2025 CPT code 1032F

Identifies a patient who is a current tobacco smoker or is currently exposed to secondhand smoke, specifically relevant for asthma management.

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 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 1137F

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

2025 CPT code 1505F

Patient does not have respiratory insufficiency (ALS).

2025 CPT code 1052F

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

2025 CPT code 1040F

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

2025 CPT code 1060F

Documentation of permanent or persistent or paroxysmal atrial fibrillation.

2025 CPT code 1451F

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

2025 CPT code 1183F

Neuropsychiatric symptoms, absent.

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 1400F

Parkinson's disease diagnosis reviewed.

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 1003F

Level of activity assessed. This code is used for performance measurement and is not a substitute for Category I codes.