Education & TrainingMedicaidMarch 28, 2024

CPT Category II code reimbursements

Beginning January 1, 2025, UniCare Health Plan of West Virginia, Inc. became Wellpoint. This article — published under the former brand — now applies to Wellpoint.

Effective 2024, you can earn additional reimbursement on health and wellness services provided to UniCare Health Plan of West Virginia, Inc. (UniCare) members. UniCare is offering reimbursement for the use of CPT® Category II codes to encourage continued improvements in member care. The use of CPT Category II codes benefits the healthcare system by providing more specific information about healthcare encounters, such as how data can be used to help UniCare providers work more efficiently and effectively in the best interest of each member.

Please note that this reimbursement only applies to Medicaid.

Reimbursement for the administrative work and effort of completing and reporting CPT Category II codes can only be claimed once per service, per member, per year, and are earned by completing the criteria for billing the CPT Category II codes listed in Table 1 on the following page.

CPT Category II codes must be billed with one of these outpatient visit codes: 99202 through 99215. Additionally, the $20 reimbursement amount must be billed on the encounter to receive payment.

The additional reimbursement applies to physicians and qualified healthcare allied practitioners, including all primary care providers (PCPs), cardiologists, endocrinologists, pulmonologists, internal medicine, nephrologists, rheumatologists, nurse practitioners, physician assistants, and federally qualified health centers.

What is a CPT Category II code?

  • A CPT Category II code provides more detailed information about the clinical service(s) performed.
  • CPT Category II codes are billed similar to the way your office bills for regular CPT codes and are placed in the same location on the claim form.

Benefits of using CPT Category II codes include:

  • A reduction in the need for UniCare to review your medical records by providing more detailed information through your claims submissions.
  • Better tracking and management of member care needs from the use of detailed information provided with the billing of CPT Category II codes.

Next steps you need to take:

  • Review the CPT Category II code billing opportunities in Table 1 and set up your billing system to bill us for the codes when applicable.
  • Be sure that you meet the criteria for billing the CPT Category II codes in Table 1 by matching the diagnosis codes and age ranges and set up your billing system to bill appropriately.

Note: All CPT Category II codes are eligible for payment only once per member, per rolling year. Continuation of payment and payment rates for billing the CPT Category II codes in Table 1 will be evaluated annually.

If you have any questions, please contact the Customer Care Center at 800-782-0095.

Take advantage of this great revenue opportunity by enhancing your billing processes. Thank you for delivering health and wellness care to our members.

Table 1

CPT II code to

include on claim

Description

Diagnosis category code to include on claim

Criteria

2024 pay

2015F

Asthma impairment assessment

J45.20-J45.998

  • Provider conducts office evaluation for a member with asthma.
  • Provider performs asthma impairment assessment (for example, symptom frequency and pulmonary function) during the visit.
  • Provider reports appropriate office visit, diagnosis code(s), and category II code 2015F.

$20

3023F

Spirometry results documented and reviewed

J40-J44.9

  • Provider conducts office evaluation for a member with a chronic respiratory condition.
  • Provider documents and reviews spirometry results in the medical record.
  • Provider reports appropriate office visit, diagnosis code(s), and category II code 3023F.

$20

3117F

For patients who have congestive heart failure: heart failure disease-specific structured assessment tool completed

I50.1-I50.9

  • Provider conducts office evaluation for a member with a heart condition.
  • Provider completes heart failure disease-specific structured assessment tool (includes lab tests, examination procedures, radiologic examination, and/or results and medical decision making).
  • Provider reports appropriate office visit, diagnosis code(s), and category II code 3117F.

$20

0513F

For patients who have hypertension: elevated blood pressure plan of care

I10-I16.9, N18.1-N18.9,

E08.00-E13.9

  • Provider conducts office evaluation for a member with hypertension or hypertensive diseases.
  • Provider completes and documents elevated blood pressure plan of care.
  • Provider reports appropriate office visit, diagnosis code(s), and category II code 0513F.

$20

3074F

For patients who have hypertension: most recent systolic blood pressure less than 130 mm Hg

I10-I16.9, I25.10-I25.9, N18.1-N18.9,

E08.00-E13.9

  • Provider conducts office evaluation for a member with hypertension.
  • Provider completes and documents systolic blood pressure when less than 130 mm Hg.
  • Provider reports appropriate office visit, diagnosis code(s), and category II code 3074F.

$20

3075F

For patients who have hypertension: most recent systolic blood pressure 130 to 139 mm Hg

I10-I16.9, I25.10-I25.9, N18.1-N18.9,

E08.00-E13.9

  • Provider conducts office evaluation for a member with hypertension.
  • Provider completes and documents systolic blood pressure when 130 to 139 mm Hg.
  • Provider reports appropriate office visit, diagnosis code(s), and category II code 3075F.

$20

3077F

For patients who have hypertension: most recent systolic blood pressure greater than or equal to 140 mm Hg

I10-I16.9, I25.10-I25.9, N18.1-N18.9,

E08.00-E13.9

  • Provider conducts office evaluation for a member with hypertension.
  • Provider completes and documents systolic blood pressure when greater than or equal to 140 mm Hg.
  • Provider reports appropriate office visit, diagnosis code(s), and category II code 3077F.

$20

3078F

For patients who have hypertension: most recent diastolic blood pressure less than 80 mm Hg

I10-I16.9, I25.10-I25.9, N18.1-N18.9,

E08.00-E13.9

  • Provider conducts office evaluation for a member with hypertension.
  • Provider completes and documents diastolic blood pressure when less than 80 mm Hg.
  • Provider reports appropriate office visit, diagnosis code(s), and category II code 3078F.

$20

3079F

For patients who have hypertension: most recent diastolic blood pressure 80 to 89 mm Hg

I10-I16.9, I25.10-I25.9, N18.1-N18.9,

E08.00-E13.9

  • Provider conducts office evaluation for a member with hypertension.
  • Provider completes and documents diastolic blood pressure when 80 to 89 mm Hg.
  • Provider reports appropriate office visit, diagnosis code(s), and category II code 3079F.

$20

3080F

For patients who have hypertension: most recent diastolic blood pressure greater than or equal to 90 mm Hg

I10-I16.9, I25.10-I25.9, N18.1-N18.9,

E08.00-E13.9

  • Provider conducts office evaluation for a member with hypertension.
  • Provider completes and documents diastolic blood pressure when greater than or equal to 90 mm Hg.
  • Provider reports appropriate office visit, diagnosis code(s), and category II code 3080F.

$20

3011F

Lipid panel results documented and reviewed

I25.10-I25.9

  • Provider conducts office evaluation.
  • Provider documents and reviews lipid panel results in the medical record.
  • Provider reports appropriate office visit, diagnosis code(s), and category II code 3011F.

$20

2022F

For patients who have diabetes: retinal eye exam documented and reviewed

E08.00-E13.9

  • Provider conducts office evaluation for a member with diabetes mellitus (type 1 or type 2).
  • Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed, with evidence of retinopathy.
  • Provider reports appropriate office visit, diagnosis code(s), and category II code 2022F.

$20

2023F

For patients who have diabetes: retinal eye exam documented and reviewed

E08.00-E13.9

  • Provider conducts office evaluation for a member with diabetes mellitus (type 1 or type 2).
  • Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed, without evidence of retinopathy.
  • Provider reports appropriate office visit, diagnosis code(s), and category II code 2023F

$20

2024F

For patients who have diabetes: retinal eye exam documented and reviewed

E08.00-E13.9

  • Provider conducts office evaluation for a member with diabetes mellitus (type 1 or type 2).
  • Seven standard field stereoscopic photos with interpretation by an ophthalmologist or optometrist documented and reviewed: with evidence of retinopathy.
  • Provider reports appropriate office visit, diagnosis code(s), and category II code 2024F.

$20

2025F

For patients who have diabetes: retinal eye exam documented and reviewed

E08.00-E13.9

  • Provider conducts office evaluation for a member with diabetes mellitus (type 1 or type 2).
  • Seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed: without evidence of retinopathy.
  • Provider reports appropriate office visit, diagnosis code(s), and category II code 2025F.

$20

2026F

For patients who have diabetes: retinal eye exam documented and reviewed

E08.00-E13.9

  • Provider conducts office evaluation for a member with diabetes mellitus (type 1 or type 2).
  • Eye imaging validated to match diagnosis from seven standard field stereoscopic photos results documented and reviewed: with evidence of retinopathy.
  • Provider reports appropriate office visit, diagnosis code(s), and category II code 2026F.

$20

2033F

For patients who have diabetes: retinal eye exam documented and reviewed

E08.00-E13.9

  • Provider conducts office evaluation for a member with diabetes mellitus (type 1 or type 2).
  • Eye imaging validated to match diagnosis from seven standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed: without evidence of retinopathy.
  • Provider reports appropriate office visit, diagnosis code(s), and category II code 2033F.

$20

3072F

For patients who have diabetes: retinal eye exam documented and reviewed

E08.00-E13.9

  • Provider conducts office evaluation for a member with diabetes mellitus (type 1 or type 2).
  • Low risk for retinopathy (no evidence of retinopathy in the prior year).
  • Provider reports appropriate office visit, diagnosis code(s), and category II code 3072F.

$20

2014F

Mental status assessed (normal/
mildly impaired/
severely impaired) (CAP)1

F90.0-F90.9

  • Provider conducts office evaluation for a member with ADD or ADHD.
  • Provider completes and documents mental status assessment.
  • Provider reports appropriate office visit, diagnosis code(s), and category II code 2014F.

$20

3085F

Suicide risk assessed (MDD)1

F32.0-F33.9

  • Provider conducts office evaluation for a member with major depressive disorder.
  • Provider completes and documents assessment of suicide risk.
  • Report appropriate office visit, diagnosis code(s), and category II code 3085F.

$20

3044F

For patients who have diabetes: most recent HbA1c less than 7

E08.00-E13.9

  • Provider conducts office evaluation for a member with diabetes mellitus (any type).
  • Provider completes and documents hemoglobin A1C results when less than 7.
  • Provider reports appropriate office visit, diagnosis code(s), and Category II code 3044F.

$20

3046F

For patients who have diabetes: most recent HbA1c
greater than 9

E08.00-E13.9

  • Provider conducts office evaluation for a member with diabetes mellitus (any type).
  • Provider completes and documents hemoglobin A1C results when greater than 9.
  • Provider reports appropriate office visit, diagnosis code(s) and Category II code 3046F.

$20

3051F

Most recent hemoglobin A1c (HbA1c) level greater than or equal to 7.0% and less than 8.0% (DM)

E08.00-E13.9

  • Provider conducts office evaluation for a member with diabetes mellitus (any type).
  • Provider completes and documents hemoglobin A1C results 7 to 8.
  • Provider reports appropriate office visit code, diagnosis code(s), and Category II code 3051F.

$20

3052F

Most recent hemoglobin A1c (HbA1c) level greater than or equal to 8.0% and less than 9.0% (DM)2

E08.00-E13.9

  • Provider conducts office evaluation for a member with diabetes mellitus (any type).
  • Provider completes and documents hemoglobin A1C results when 8 to 9.
  • Provider reports appropriate office visit code, diagnosis code(s), and Category II code 3052F.

[$20

3475F

Disease prognosis for rheumatoid arthritis assessed, poor prognosis documented

M05.00.00-M06.9

  • Provider conducts office evaluation for a member with rheumatoid arthritis.
  • Provider completes and documents rheumatoid arthritis assessment with a poor prognosis.
  • Provider reports appropriate office visit, diagnosis code(s), and category II code 3475F.

$20

3476F

Disease prognosis for rheumatoid arthritis assessed, good prognosis documented

M05.00-M06.9

  • Provider conducts office evaluation for a member with rheumatoid arthritis.
  • Provider completes and documents rheumatoid arthritis assessment with a good prognosis.
  • Provider reports appropriate office visit, diagnosis code(s), and category II code 3476F.

$20

3500F

CD4+ cell count or CD4+ cell percentage documented as performed (HIV)5

B20, Z21, B97.35, O98.711

  • Provider conducts office evaluation for a member with HIV/AIDS-related diagnosis.
  • Provider completes and documents CD4+ cell count or CD4+ cell percentage in the medical record.
  • Provider reports appropriate office visit, diagnosis code(s), and category II code 3500F.

$20

3066F

Documentation of treatment for nephropathy (for example, patient receiving dialysis, patient being treated for)

N04.0-N18.9, E08.00-E11.9, E13.00-E13.9

  • Provider conducts office evaluation for a member with nephropathy or CKD diagnosis.
  • Provider completes and documents treatment for nephropathy/CKD in the medical record.
  • Provider reports appropriate office visit, diagnosis code(s), and category II code 3066F.

$20

UniCare Health Plan of West Virginia, Inc.
Mountain Health Trust

WVUNI-CD-054286-24

PUBLICATIONS: May 2024 Provider Newsletter