Medical Coding

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G8473Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy prescribed
G8474Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy not prescribed for reasons documented by the clinician (e.g., allergy, intolerance, pregnancy, renal failure due to ACE inhibitor, diseases of the aortic or mitral
G8475Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy not prescribed, reason not given
G8506Patient receiving angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy
G8935Clinician prescribed angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy
G8936Clinician documented that patient was not an eligible candidate for angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy (e.g., allergy, intolerance, pregnancy, renal failure due to ACE inhibitor, diseases of the aor
G8937Clinician did not prescribe angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy, reason not given
G0442Annual alcohol misuse screening, 15 minutes
G0443Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes
G9621Patient identified as an unhealthy alcohol user when screened for unhealthy alcohol use using a systematic screening method and received brief counseling
G9622Patient not identified as an unhealthy alcohol user when screened for unhealthy alcohol use using a systematic screening method
H0049Alcohol and/or drug screening
G0447G0447 Face-to-face behavioral counseling for obesity, 15 minutes
G0473G0473 Face-to-face behavioral counseling for obesity, group (2-10), 30 minutes
G8417G8417 BMI is documented above normal parameters and a follow-up plan is documented
G8418G8418 BMI is documented below normal parameters and a follow-up plan is documented
G8419G8419 BMI documented outside normal parameters, no follow-up plan documented, no reason given
G8420G8420 BMI is documented within normal parameters and no follow-up plan is required
G8421G8421 BMI not documented and no reason is given
G8422BMI not documented, documentation the patient is not eligible for BMI calculation
G8938G8938 BMI is documented as being outside of normal limits, follow-up plan is not documented, documentation the patient is not eligible
G9716G9716 BMI is documented as being outside of normal limits, follow-up plan is not completed for documented reason
G0101 Cervical or vaginal cancer screening; pelvic and clinical breast examination
G0104 Colorectal cancer screening; flexible sigmoidoscopy
G0105 Colorectal cancer screening; colonoscopy on individual at high risk
G0106Colorectal cancer screening; alternative to G0104, screening sigmoidoscopy, barium enema
G0120 Colorectal cancer screening; alternative to G0105, screening colonoscopy, barium enema
G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk
G0122 Colorectal cancer screening; barium enema
G0328 Colorectal cancer screening; fecal occult blood test, immunoassay, 1-3 simultaneous determinations
G9659 Patients greater than 85 years of age who did not have a history of colorectal cancer or valid medical reason for the colonoscopy, including: iron deficiency anemia, lower gastrointestinal bleeding, Crohn's disease (i.e., regional enteritis), familial ade
G9711 Patients with a diagnosis or past history of total colectomy or colorectal cancer
G9660 Documentation of medical reason(s) for a colonoscopy performed on a patient greater than 85 years of age (e.g., last colonoscopy incomplete, last colonoscopy had inadequate prep, iron deficiency anemia, lower gastrointestinal bleeding, Crohn's disease (i.
G8431Screening for depression is documented as being positive and a follow-up plan is documented
G8432Depression screening not documented, reason not given
G8433 Screening for depression not completed, documented reason
G0444 Annual depression screening, 15 minutes
G8510 Screening for depression is documented as negative, a follow-up plan is not required
G8511 Screening for depression documented as positive, follow-up plan not documented, reason not given
G9717 Documentation stating the patient has an active diagnosis of depression or has diagnosed bipolar disorder, therefore screening or follow-up not required
G0108 Diabetes outpatient self-management training services, individual, per 30 minutes
G0109 Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes
G0245Initial physician evaluation and management of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation (LOPS) which must include: (1) the diagnosis of LOPS, (2) a patient history, (3) a physical examination that con
G9676 Patients aged 40 to 75 years at the beginning of the measurement period with type 1 or type 2 diabetes and with an LDL-C result of 70/189 mg/dl recorded as the highest fasting or direct laboratory test result in the measurement year or during the two year
G9783 Documentation of patients with diabetes who have a most recent fasting or direct LDL- C laboratory test result < 70 mg/dl and are not taking statin therapy
J1815 Injection, insulin, per 5 units
J1817 Insulin for administration through DME (i.e., insulin pump) per 50 units
S0390 Routine foot care; removal and/or trimming of corns, calluses and/or nails and preventive maintenance in specific medical conditions (e.g., diabetes), per visit
2028FFoot examination performed (includes examination through visual inspection, sensory exam with monofilament, and pulse exam - report when any of the 3 components are completed) (DM)
G9225Foot exam was not performed, reason not given
G9226 Foot examination performed (includes examination through visual inspection, sensory exam with 10-g monofilament plus testing any one of the following: vibration using 128-Hz tuning fork, pinprick sensation, ankle reflexes, or vibration perception threshol
G9502 Documentation of medical reason for not performing foot exam (i.e., patients who have had either a bilateral amputation above or below the knee, or both a left and right amputation above or below the knee before or during the measurement period
G8535Elder maltreatment screen not documented; documentation that patient not eligible for the elder maltreatment screen
G8536No documentation of an elder maltreatment screen, reason not given
G8733 Elder maltreatment screen documented as positive and a follow-up plan is documented
G8734Elder maltreatment screen documented as negative, no follow-up required
G8735Elder maltreatment screen documented as positive, follow-up plan not documented, reason not given
G8941Elder maltreatment screen documented as positive, follow-up plan not documented, documentation the patient is not eligible
0518FFalls plan of care documented (GER)
99487Complex chronic care management services, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions place the patient at significant risk of d
99489Complex chronic care management services, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions place the patient at significant risk of d
99490Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: multiple (two or more) chronic conditions expected
1100FPatient screened for future fall risk; documentation of 2 or more falls in the past year or any fall with injury in the past year (GER)
1101FPatient screened for future fall risk; documentation of no falls in the past year or only 1 fall without injury in the past year (GER)
3288FFalls risk assessment documented (GER)
99487 Complex chronic care management services, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions place the patient at significant risk of d
99489Complex chronic care management services, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions place the patient at significant risk of d
99490 Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: multiple (two or more) chronic conditions expected
G0446Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes
G8451Beta-blocker therapy for LVEF < 40% not prescribed for reasons documented by the clinician (e.g., low blood pressure, fluid overload, asthma, patients recently treated with an intravenous positive inotropic agent, allergy, intolerance, other medical reaso
G8476Most recent blood pressure has a systolic measurement of < 140 mm Hg and a diastolic measurement of < 90 mm Hg
G8477Most recent blood pressure has a systolic measurement of >=140 mm Hg and/or a diastolic measurement of >=90 mm Hg
G8478Blood pressure measurement not performed or documented, reason not given
G8752Most recent systolic blood pressure < 140 mm Hg
G8753Most recent systolic blood pressure >= 140 mm Hg
G8754Most recent diastolic blood pressure < 90 mm Hg
G8755Most recent diastolic blood pressure >= 90 mm Hg
G8756No documentation of blood pressure measurement, reason not given
G8783Normal blood pressure reading documented, follow-up not required
G8785Blood pressure reading not documented, reason not given
G8950Prehypertensive or hypertensive blood pressure reading documented, and the indicated follow-up is documented
G8952Prehypertensive or hypertensive blood pressure reading documented, indicated follow-up not documented, reason not given
G9273Blood pressure has a systolic value of < 140 and a diastolic value of < 90
G9274Blood pressure has a systolic value of = 140 and a diastolic value of = 90 or systolic value < 140 and diastolic value = 90 or systolic value = 140 and diastolic value < 90
G9745Documented reason for not screening or recommending a follow-up for high blood pressure
G9745Documented reason for not screening or recommending a follow-up for high blood pressure
G9789Blood pressure recorded during inpatient stays, emergency room visits, urgent care visits, and patient self-reported BP's (home and health fair BP results)
G9790Most recent BP is greater than 140/90 mm Hg, or blood pressure not documented
J1815 Injection, insulin, per 5 units
J1817 Insulin for administration through DME (i.e., insulin pump) per 50 units
0005F Osteoarthritis assessed (OA) Includes assessment of all the following components: Osteoarthritis symptoms and functional status assessed (1006F) Use of anti-inflammatory or over-the-counter (OTC) analgesic medications assessed (1007F) Initial examination
1006F Osteoarthritis symptoms and functional status assessed (may include the use of a standardized scale or the completion of an assessment questionnaire, such as the SF-36, AAOS Hip & Knee Questionnaire) (OA) [Instructions: Report when osteoarthritis is addre
1008F Gastrointestinal and renal risk factors assessed for patients on prescribed or OTC non-steroidal anti-inflammatory drug (NSAID) (OA)
1007F Use of anti-inflammatory or analgesic over-the-counter (OTC) medications for symptom relief assessed (OA)
2004F Initial examination of the involved joint(s) (includes visual inspection, palpation, range of motion) (OA) [Instructions: Report only for initial osteoarthritis visit or for visits for new joint involvement]
20610 Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance
3470F Rheumatoid arthritis (RA) disease activity, low (RA)
3471F Rheumatoid arthritis (RA) disease activity, moderate (RA)
3472F Rheumatoid arthritis (RA) disease activity, high (RA)
3475F Disease prognosis for rheumatoid arthritis assessed, poor prognosis documented (RA)
3476F Disease prognosis for rheumatoid arthritis assessed, good prognosis documented (RA)
G9472 Within the past 2 years, central dual-energy x-ray absorptiometry (DXA) not ordered and documented, no review of systems and no medication history or pharmacologic therapy (other than minerals/vitamins) for osteoporosis prescribed
G8633 Pharmacologic therapy (other than minerals/vitamins) for osteoporosis prescribed
G8635Pharmacologic therapy for osteoporosis was not prescribed, reason not given
G9769 Patient had a bone mineral density test in the past two years or received osteoporosis medication or therapy in the past 12 months
G8861 Within the past 2 years, central dual-energy x-ray absorptiometry (DXA) ordered and documented, review of systems and medication history or pharmacologic therapy (other than minerals/vitamins) for osteoporosis prescribed
G8863 Patients not assessed for risk of bone loss, reason not given
G0402 Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment
G0403 Electrocardiogram, routine ECG with 12 leads; performed as a screening for the initial preventive physical examination with interpretation and report
G0404Electrocardiogram, routine ECG with 12 leads; tracing only, without interpretation and report, performed as a screening for the initial preventive physical examination
G0405Electrocardiogram, routine ECG with 12 leads; interpretation and report only, performed as a screening for the initial preventive physical examination
G0445 Semiannual high intensity behavioral counseling to prevent STIs, individual, face-to-face, includes education skills training & guidance on how to change sexual behavior
G0008Administration of influenza virus vaccine
G0009Administration of pneumococcal vaccine
G0010 Administration of hepatitis B vaccine
G8482Influenza immunization administered or previously received
G8483 Influenza immunization was not administered for reasons documented by clinician (e.g., patient allergy or other medical reasons, patient declined or other patient reasons, vaccine not available or other system reasons)
G8484Influenza immunization was not administered, reason not given
G8864 Pneumococcal vaccine administered or previously received
G8865 Documentation of medical reason(s) for not administering or previously receiving pneumococcal vaccine (e.g., patient allergic reaction, potential adverse drug reaction)
G8866Documentation of patient reason(s) for not administering or previously receiving pneumococcal vaccine (e.g., patient refusal)
G8867Pneumococcal vaccine not administered or previously received, reason not given
G9507 Documentation that the patient is on a statin medication or has documentation of a valid contraindication or exception to statin medications; contraindications/exceptions that can be defined by diagnosis codes include pregnancy during the measurement peri
G9508 Documentation that the patient is not on a statin medication
G9663 Any fasting or direct LDL-C laboratory test result = 190 mg/dl
G9664 Patients who are currently statin therapy users or received an order (prescription) for statin therapy
G9665 Patients who are not currently statin therapy users or did not receive an order (prescription) for statin therapy
G9666 The highest fasting or direct LDL-C laboratory test result of 70/189 mg/dl in the measurement period or two years prior to the beginning of the measurement period
G9675 Patients who have ever had a fasting or direct laboratory result of LDL-C = 190 mg/dl
G9676 Patients aged 40 to 75 years at the beginning of the measurement period with type 1 or type 2 diabetes and with an LDL-C result of 70/189 mg/dl recorded as the highest fasting or direct laboratory test result in the measurement year or during the two year
G9781 Documentation of medical reason(s) for not currently being a statin therapy user or receive an order (prescription) for statin therapy (e.g., patient with adverse effect, allergy or intolerance to statin medication therapy, patients who are receiving pall
G9783 Documentation of patients with diabetes who have a most recent fasting or direct LDL- C laboratory test result < 70 mg/dl and are not taking statin therapy
G9796 Patient is currently on a statin therapy
G9797 Patient is not on a statin therapy
G8816 Statin medication prescribed at discharge
G8817 Statin therapy not prescribed at discharge, reason not given
G8815 Documented reason in the medical records for why the statin therapy was not prescribed (i.e., lower extremity bypass was for a patient with non-artherosclerotic disease)
1000F Tobacco use assessed (CAD, CAP, COPD, PV) (DM)
1032FCurrent tobacco smoker or currently exposed to secondhand smoke (Asthma)
1033FCurrent tobacco non-smoker and not currently exposed to secondhand smoke (Asthma)
1034FCurrent tobacco smoker (CAD, CAP, COPD, PV) (DM)
1035FCurrent smokeless tobacco user (eg, chew, snuff) (PV)
1036FCurrent tobacco non-user (CAD, CAP, COPD, PV) (DM) (IBD)
G9458Patient documented as tobacco user and received tobacco cessation intervention (must include at least one of the following: advice given to quit smoking or tobacco use, counseling on the benefits of quitting smoking or tobacco use, assistance with or refe
G9459Currently a tobacco non-user
G9460Tobacco assessment or tobacco cessation intervention not performed, reason not given
G9791 Most recent tobacco status is tobacco free
G9792 Most recent tobacco status is not tobacco free
99406Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes
99407 Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes
99408Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes
99409Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; greater than 30 minutes
0509F Urinary incontinence plan of care documented (GER)
1090F Presence or absence of urinary incontinence assessed (GER)
1091F Urinary incontinence characterized (eg, frequency, volume, timing, type of symptoms, how bothersome) (GER)
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