CPT® II Coding for Closing Care

Gaps

CPT Copyright 2022, American Medical Association. All rights reserved. 1

1 CPT® is a registered trademark of the American Medical Association.
Learning Objectives

● Understand CPT II codes and their role in improving quality performance

● Learn how payers differ in their method for closing quality care gaps
● Identify how the CPT II codes can be integrated into practice workflows
● Understand CPT II coding nuances for top Quality Measure satisfaction

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 Aledade Disclaimer
This guidance is intended to help healthcare providers accurately and
completely code and/or bill services that, with proper documentation, may
be reimbursable by a state or Federal healthcare program. This information
is a tool for addressing common billing and coding issues, which are
explained more fully in the CPT® Manual and the official, CMS-approved
ICD-10 guidelines. You should review the CPT® Manual as well as the
official, CMS-approved, ICD-10 guidelines and not rely exclusively on this
informational material. Each healthcare provider bears full responsibility for
its own billing and coding, as well as compliance with all applicable Federal
and state laws and regulations.
This tool provides education on methodology and is not intended to guide
deliberate selection of one diagnosis over another. Diagnoses should always
reflect clinical documentation.

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Defining Current Procedural Terminology (CPT) Category II Codes

Category II CPT codes (or “CPT II”) and their application to quality performance in Value-Based Contracts

Difference Between CPT and CPT II Codes

CPT codes, or Category I codes, are used to bill payers for services performed in our practices (e.g. 99213,
G0438, 93000).

CPT II codes are used to communicate clinical and/or quality information and generate no revenue. They are
$0.00 or $0.01 claims that can be included in a visit bill or submitted separately to close quality gaps. Examples
on how to code CPT II’s will be demonstrated later in the presentation.

According to the AMA:

CPT Category II codes are supplemental tracking codes that can be used for performance
measurement. The use of the tracking codes for performance measurement will decrease the need
for record abstraction and chart review, and thereby minimize administrative burdens on physicians
and other health care professionals.

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The Importance of CPT II Codes
CPT II codes present the opportunity to close some preventative and chronic care care gaps in some
Medicare Advantage, Commercial and Medicaid contracts

For Patients:
- Encourages patients get the highest standard of care with a focus on
preventative services
- Encourages better patient health outcomes
Good for - Improves accuracy of medical records
Practices
For Practices:
- Allows for practices to get credit and paid for the work they do to
deliver quality care in a value-based environment.
- Reduces medical record requests for care already provided
Good for Good for - Minimizes administrative burdens associated with chasing quality
gaps later in the year.
Society Patients
For Society:
- Improves tracking of population health

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Top Quality Measures Satisfied via CPT II Codes
These three quality measures are both very frequently occurring and are satisfied through use of CPT II codes.
These measures below can make a large impact on gap closure while producing limited administrative burden by using CPT II codes.

Measure CPT II Codes

Diabetes Care: HbA1c Payers use the last measurement of the year, therefore it is important to submit a claim with the 2 appropriate CPT II codes to report
Controlled* (<8% or = results of the A1c at each routine office visit:
≤9%) ● 3044F: HbA1c less than 7.0%
● 3051F: HbA1c ≥ 7.0% BUT less than 8.0%
*Controlled % may vary by ● 3052F: HbA1c ≥ 8.0% and ≤ 9.0%
● 3046F: HbA1c greater than 9.0%
payer contract
NOTE: When submitting any CPT II codes, do not use the modifiers 1P, 2P, or 8P. These modifiers indicate that the service was not
done and will exclude the CPT II code from the care gap calculations.

Controlling High Blood Payers use the last measurement of the year, therefore it is important to submit a claim with the 2 appropriate CPT II codes to report
Pressure results of the BP at each routine office visit:
● SBP < 140 mmHG: 3074F - controlled
● SBP 130-139 mmHB: 3075F - controlled
● SBP ≥ 140 mmHG: 3077F - not controlled
● DBP <80 mmHG: 3078F - controlled
● DPB 80-89 mmHG: 3079F - controlled
● DBP ≥ 90 mmHg: 3080F - not controlled

Diabetic Eye Exam ● Current year dilated retinal screening with evidence of retinopathy; CPT II: 2022F, 2024F, 2026F
● Current year dilated retinal screening without evidence of retinopathy; CPT II: 2023F, 2025F, 2033F
● Low risk for retinopathy (no evidence of retinopathy in the prior year): 3072F (Do not use this code at the time of the exam; use
it the following year to indicate retinopathy was not present the previous year)
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Quality Impacts on Value-Based Contract Performance
Value-Based Contracting Encourages a Shift from Volume to Value
Provider groups in ACOs can earn shared savings by ensuring that the total cost of care (TCOC) for their patient
population is lower than the payer’s anticipated total cost, while maintaining/improving quality of care.

The total expected cost of a patient The benchmark is set via communicating
population is called a benchmark. patient clinical complexity via ICD-10*
codes on claims, also known as,
diagnosis documentation.

1 2

ACOs can come in under benchmark by Payers establish Quality Measures (QMs) to
providing high-quality care, via reducing demonstrate that practices are: (a) engaging
admissions and providing wellness services, with patients instead of withholding care and
access to preventive screenings, and (b) engaging in treatments/behaviors that lead
managing chronic conditions. to lower longer-term health care expenditures
and improved patient quality.
3 4
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*International Classification of Diseases, tenth edition
What Impact Do Quality Measures Have On Contract Performance?
Quality Measures are included in all types of Value-Based contracts, but have different structural
implications depending on the insurance type, payer and contract.

Quality-Determined Shared
Quality as a Gate
Savings Rates
A baseline target score must be met to "open the gate" Shared savings is impacted by quality
to receive any other financial incentives (such as shared performance → the more measures an ACO
savings). passes, the more savings an ACO is able to access.

Quality as an Incremental Bonus

Payment
Improved quality performance provides small lump
sum bonus payments to practices.

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 Payer Differences in Quality Care Gap Closures

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Defining Submission Methods for Payer Care Gap Closure
Depending on the payer, different submission methods can be used to close different payer care gaps. Once practices submit the data
documenting the services rendered, payers assess whether it satisfies the quality measure.

Submission Methods
Claims CPT II Codes Supplemental Data Flat File submission (from
CPT/G-Code measures CPT II codes are Submission (upload) Aledade)
are satisfied by being submitted by practices A manual process whereby When Aledade has a record of
submitted and accepted and ingested via the practices upload clinical a care gap closure at the
by the payer via the claims submission documentation to support patient level (typically clinical
claims submission process gap closure (typically PDFs data, such as BP, A1c and BMI),
process of the medical record it will submit a large data file to
uploaded to a payer portal) the payer on behalf of all
practices in the ACO
Ingestion Process: Payers process claims
(including CPT II codes included on
claims) and data submissions on a Closure + Aledade App Activity Ingestion Process: Unlike Claims & CPT II
regular cadence. Reflection: Once the payer has a ingestion, which can take up to 90 days to
record of the care gap being “closed” or process, Supplemental Data Submission or Flat
Due to the internal processes required to “satisfied” in the measurement year, File Submission can take anywhere from 6 weeks
integrate the data transmission, it can they will update their files. to 6 months for payers to process.
take 90+ days after action has been taken
by the practice for a care gap to be Aledade will then upload the updated This is why CPT II coding is recommended
reflected as “closed” by a payer. files into the Aledade App. Upon for applicable payers – it will be processed
ingestion of a file indicating that a gap more quickly and be reflected in the data
has been closed on record with a faster!
payer, the gap will “close” and
10 disappear from the Aledade App.
Payers & CPT II Code Submissions
CPT II codes are one of the methods that practices can use to submit data to close certain quality metrics (QMs).
When they are accepted, CPT II codes are an efficient, helpful way to document services rendered.

Payer Type Ways to Satisfy QMs for Contract Generally Accepts CPT II Codes for QM Satisfaction

MSSP Claims No
Clinical Data attestation (GPro)

Medicare Claims Yes

Advantage CPT II Codes
Supplemental Data Uploads
Flat File Submission (from Aledade)**

Commercial Claims Yes

CPT II Codes
Supplemental Data Uploads*
Flat File Submission (from Aledade)**

Medicaid Claims Yes

CPT II Codes
Supplemental Data Uploads*
Flat File Submission (from Aledade)**

11 * supplemental data uploads varies by payer

**flat file submission is limited to A1c, BP, BMI pending data availability
Delays Happen! - Payers process claims and data differently

What Practices Have Shared What the payer wants you to consider
“The patient just had an FOBT in November Although the FOBT was done within the past 12 months, it would still need to be
of 2021, they are not due and they shouldn’t performed in the measurement YEAR. Yes, most payers will always allow for this to
be on this list. Also, the insurance isn’t going be completed.
to pay for it again.”

“They weren’t even in our patient until this Many, if not most, practices obtain outside or older notes on their patients as they
year.” become established in their practice. Reviewing those outside notes often provide
great insights and close gaps. Depending on the payer it could be as simple as an
upload.

“We have only seen them for an urgent This is a great opportunity to review and remind the patient of the importance of the
care/sick visit this year.” relationship with the PCP and having the annual visit provided. Typically an urgent
care visit/sick visit also includes a BP/BMI and often labs and medication adherence
opportunities.

“The payer paid the claim why is still on the We may have paid the claim however, depending on the gap a measure may remain
list as a gap when they know it was done?” on the list as the current outcome indicates a fail.

“We have limited staff and time, why do I Your EHR does not send a note when submitting a claim. Utilizing the CPT II codes
need to add or send a CPT II code on the claim ensures that gaps are closed, allows for performance recognition and identifies the
when the information is in my note?” outcome of the service.

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 Integrating CPT II Coding into Practice Workflows

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Integrating CPT II Coding into Practice Workflows
Using the Care Gap Worklist can help practices identify patients that are in need of closing care gaps. CPT II codes help report
clinicians on evidence based performance guidelines for improving quality of patient care.

Pre-Visit Planning At Visit (Point-of-Care) Non-Visit Workflows

● Use Care Gap Work List ● The clinical support staff ● Billing departments can
in the Aledade App to can highlight for the help clinicians ensure
help staff identify patients physician/NP/PA the capture CPT II codes by
who are not meeting the open care gaps by suggesting and
care gaps measures. printing out the daily recommending
● The Worklist triggers the huddle appropriate codes for
staff to schedule ● CPT II codes help close documentation.
appointments for patients the care gaps the ● Close the encounter and
that are due for visit to physician/NP/PA is trying send it to the payer
close care gap. to complete during the ● Once billed,
visit administrative staff can
● Some EHRs can use move it to payer
default CPT II codes to confirmation in the
appropriate diagnosis to Aledade App to
help close the measure eliminate them from the
14 too! Care Gap Work List
Documenting CPT II Codes on Claims associated with Patient Encounters

Automating CPT II Code Transmission CPT II Code Documentation

Practices that use athenaNet, eCW, and some other For practices not using athenaNet or eCW or who would
EHRs can work with their EHR vendors to automate the prefer to manually input CPT II codes onto their claims, they
should follow the following guidelines:
inclusion of some CPT II codes into their charge
1. Validate that the service was completed / clinical value
entry/claim creation processes.
was captured in the EHR
2. Review if the patient meets any exclusion criteria, and
if yes - ensure the exclusion criteria is documented
3. Include the appropriate CPT II code on the claim form,
ensuring it is mapped to the appropriate diagnosis
a. CPT II codes can go in the CPT section of a
charge entry page/claim form or in a dedicated
CPT II column

*PRO TIP: do not map irrelevant ICD-10 diagnosis to CPT II codes, as

those codes will be “cut off” when they hit the payer and not be
processed by the payer for diagnosis documentation (clinical complexity
calculation) purposes
*Some EHRs also allow practices to create favorite lists which may make
it easier to add to the visit note.
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 Tips for Coding & Billing

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Anatomy of a Claim Form: Where to put the CPT II Codes
Example of CPT II Codes on a Claim Form
Encounter CPT Code
Box 21
Encounter ICD-10
Diagnosis Codes

Box 24 (F)
Charges

Box 24 (E)
Diagnosis Code
Mapping: Relating
the CPT and CPT II
Codes to the ICD-10
Diagnosis Codes

Box 24 (D) Procedure & CPT II Codes

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Billing Penny Codes
● If a healthcare billing software does not allow a $0.00 line-item charge, a nominal amount can
be substituted such as 1 penny ($0.01) [See below]
● *The beneficiary is not liable for this nominal amount.*
Encounter CPT Code
Non- Encounter
based CPT II codes
(Penny Codes)
Know the Payer:
They may require a
penny or a
zero dollar amount

CPT II Code
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Billing HbA1C: Ensuring Value Communication
● A practice can use CPT II codes to report A1C values but values vary from payer to payer:
○ Quality Measure compliance for A1C control for Medicare Advantage (MA) plans is typically
HBA1C <9
○ Quality Measure compliance for A1C control for Commercial plans can require <8
● Be sure to use the correct CPT II code to match the A1C value!

CPT II Reporting Codes for A1C:

● 3044F: HbA1c less than 7.0%
● 3051F: HbA1c ≥ 7.0% BUT less than
8.0%
● 3052F: HbA1c ≥ 8.0% and ≤ 9.0%
● 3046F: HbA1c greater than 9.0%

Directions for correctly getting the CPT II

Code on a Claim:
● In box 21, ensure a diabetes
diagnosis is included in (ideally) the
first 4 diagnoses
● In box 24 (D) add the correct CPT II
code that matches the A1C range of
the patient results
● On the same line as the CPT II code,
in box 24 (E) point to the diabetes
diagnosis from box 21

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Billing Blood Pressure: Ensuring Correct Data is Communicated
● Often during a visit, practitioners take more than one blood pressure, especially if out of range
on the first reading.
● Practices can provide CPT II codes for the repeat reading, as it is the most recent reading for the
patient; this can help to close the Controlling Blood Pressure Measure.

This data from the chart can be

sent to the payer via CPT II
coding

CPT II Reporting Codes for

reporting Blood Pressure:
● SBP < 140 mmHG: 3074F -
controlled
● SBP 130-139 mmHB: 3075F
- controlled
● SBP ≥ 140 mmHG: 3077F -
not controlled
● DBP <80 mmHG: 3078F -
controlled
● DPB 80-89 mmHG: 3079F -
controlled
● DBP ≥ 90 mmHg: 3080F -
not controlled

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Diabetic Eye Exams: A One-Time Quality Measure
● Unlike the HbA1c testing and Controlling Blood Pressure measures, the Diabetic Eye Exam quality measure is
satisfied through a one-time procedure code per year, regardless of the outcome
● Closing Diabetic Eye exams through CPT II codes is a quick way to close care gaps for patients who have already
had an eye exam

CPT II Reporting Codes for reporting Diabetic Eye

exams:
● Current year dilated retinal screening with
evidence of retinopathy CPT II: 2022F, 2024F,
2026F
● Current year dilated retinal screening without
evidence of retinopathy CPT II: 2023F, 2025F,
2033F
● Low risk for retinopathy (no evidence of
retinopathy in the prior year): 3072F (Do not
use this code at the time of the exam; use it
the following year to indicate retinopathy was
not present the previous year.

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Common Pitfalls & Frequently Asked Questions
What code do I use for medication reconciliation outside of a Transitional Care Management visit?
● During a regular office visit when reviewing medications with a patient the correct CPT II codes are:
○ 1159F (medication list is documented in the medical record)
○ 1160F (all medications reviewed by a prescriber) During a transitional care management visit
● During a Transitional Care Management (TCM) visit:
○ 1111F code is used to indicate that discharge medications were reconciled with the patient’s current medication
list in the medical record

Will a CPT II code report on a UB-04 form?

● No, The UB-04 (CMS-1450) form is the claim form primarily used by hospitals or outpatient facilities for services rendered
such as surgery, radiology, or laboratory. The UB-04 form does not have an acceptable location to report CPT II codes and
is not an acceptable submission for CPT II codes.
○ This is important, especially for FQHC’s
● The HCFA-1500 form (CMS-1500) is a form that does support the use of CPT II codes (check with plan to know if HCFA
form is permitted)

Why was my claim denied with a CPT II code? OR I don’t see the CPT II code on the Explanation of Benefits?
● It is likely that a claim could be denied because the CPT II code was not pointing to a diagnosis or if it was pointing to a
diagnosis it could have been pointing to a diagnosis that extended beyond the initial 12 diagnoses listed, leading to a
claims
○ Whether by accident or intentionally, medical billing and coding errors are common reasons that claims are rejected
or denied.

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 Key Takeaways

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Key Takeaways

● CPT II codes are used to communicate clinical and/or quality information and generate
no revenue. They are $0.00 or $0.01 claims that can be included in a visit bill or
submitted separately to close quality gaps.

● CPT II codes are an efficient way to close preventative and chronic care quality
measures such as:
○ Diabetic HbA1c values
○ Controlling High Blood Pressure
○ Diabetic Eye exams

● Billing CPT II codes take practice, but using a guide or a visual tool, like provided in this
deck can help ensure from encounter closure through the clearing house that gaps are
closed

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