HEDIS Code Quick Reference Guide—Women’s Health Services · 2 Pregnancy Care Postpartum Care...
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Transcript of HEDIS Code Quick Reference Guide—Women’s Health Services · 2 Pregnancy Care Postpartum Care...
HEDIS Code Quick Reference Guide—Women’s Health Services
1
HEDIS Code Quick Reference Guide—Women’s Health Services
Women’s Health
Breast Cancer Screening (ages 40-69) [Commercial, Medicaid, Medicare]
Codes to identify Breast Cancer Screening
CPT HCPCS ICD-9-CM Procedure UB Revenue
77055-77057 G0202, G0204, G0206 87.36, 87.37 0401, 0403
EXCLUSIONS: CPT ICD-9-CM Procedure
Bilateral mastectomyUse Unilateral code WITH bilateral modifier .50 or 09950 to
indicate the procedure was bilateral and performed during the same operative session.
85.42, 85.44, 85.46, 85.48
Unilateral mastectomy 19180, 19200, 19220, 19240, 19303-19307 (Modifiers: Right=RT, Left=LT) 85.41, 85.43, 85.45, 85.47
Cervical Cancer Screening (ages 21-64) [Commercial, Medicaid]
Codes to identify Cervical Cancer Screening
CPT HCPCS ICD-9-CM Procedure UB Revenue LOINC
88141-88143, 88147, 88148, 88150, 88152-88155, 88164-88167, 88174, 88175
G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091 91.46 0923
10524-7, 18500-9, 19762-4, 19764-0, 19765-7, 19766-5, 19774-9, 33717-0, 47527-7,
47528-5
EXCLUSIONS: CPT ICD-9-CM Diagnosis ICD-9-CM Procedure
Hysterectomy51925, 56308, 57540, 57545, 57550, 57555, 57556, 58150, 58152, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290-58294, 58548, 58550-
58554, 58570-58573, 58951, 58953, 58954, 58956, 59135
618.5, V67.01, V76.47, V88.01, V88.03, 752.43 68.4-68.8
Chlamydia Screening in Women (ages 16-24) [Commercial, Medicaid]
Codes to identify Chlamydia Screening
CPT LOINC
87110, 87270, 87320, 87490-87492, 87810
557-9, 560-3, 4993-2, 6349-5, 6354-5, 6355-2, 6356-0, 6357-8, 14463-4, 14464-2, 14467-5, 14470-9, 14471-7, 14474-1, 14509-4, 14510-2, 14513-6, 16600-9, 16601-7, 21189-6, 21190-4, 21191-2, 21192-0, 21613-5, 23838-6, 31771-9, 31772-7, 31775-0, 31777-6, 36902-5, 36903-3, 42931-6, 43304-5, 43404-3, 43406-8, 44806-8, 44807-6, 45067-6, 45068-4, 45069-2, 45070-0, 45074-2, 45076-7, 45078-3,
45080-9, 45084-1, 45091-6, 45095-7, 45098-1, 45100-5, 47211-8, 47212-6, 49096-1, 50387-0, 53925-4, 53926-2
EXCLUSIONS: CPT UB Revenue LOINC
Pregnancy test 81025, 84702, 84703 9252106-3, 2107-1, 2110-5, 2111-3, 2112-1, 2113-9, 2114-7, 2115-4, 2118-8, 2119-6, 19080-1, 19180-9, 20415-6, 20994-0, 21198-7, 25372-4, 25373-2,
34670-0, 45194-8, 55869-2, 55870-0, 56497-1
WITH
Diagnostic radiology 70010-76499 032x
Retinoid Isotretinoin prescription
2
Pregnancy Care
Postpartum Care [Commercial, Medicaid]
Codes to identify Postpartum Visits
CPT (Preferred Codes) CPT Category II HCPCS ICD-9-CM
DiagnosisICD-9-CM Procedure UB Revenue LOINC
57170, 58300, 59400,* 59410,* 59430, 59510,* 59515,* 59610,* 59614,* 59618,*
59622,* 88141-88143, 88147, 88148, 88150, 88152-88155, 88164-88167, 88174, 88175, 99501 (*Generally, these codes are used on the date of delivery. Code may be used only if
the claim form indicates when postpartum care was rendered.)
0503F
G0101, G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000,
P3001, Q0091
V24.1, V24.2, V25.1, V72.3,
V76.289.26, 91.46 0923
10524-7, 18500-9, 19762-4, 19764-0, 19765-7, 19766-5, 19774-9, 33717-0, 47527-7,
47528-5
Prenatal Care [Commercial, Medicaid]
Basic Codes to identify Prenatal Care Visits
CPT ICD-9-CM Diagnosis
59400,* 59425,* 59426,* 59510,* 59610,* 59618* (* Generally, these codes are used on the date of delivery. Code is useful only if the claim form indicates when
prenatal care was initiated.)WITH
640.x3, 641.x3, 642.x3, 643.x3, 644.x3, 645.x3, 646.x3, 647.x3, 648.x3, 649.x3, 651.x3, 652.x3, 653.x3, 654.x3, 655.x3, 656.x3, 657.x3, 658.x3, 659.x3, 678.x3,
679.x3, V22, V23, V28
CPT Category II
0500F, 0501F, 0502F
Well Care
Adults’ Access to Preventive/Ambulatory Health Services
(ages 20-65) [Commercial, Medicaid, Medicare]
Codes to identify Ambulatory or Preventive Care Visit
Description CPT HCPCS ICD-9-CM Diagnosis UB Revenue
Office or other outpatient services 99201-99205, 99211-99215, 99241-99245
051x, 0520-0523, 0526-0529, 0982,
0983
Home services 99341-99345, 99347-99350
Nursing facility care 99304-99310, 99315, 99316, 99318
Domiciliary, rest home or custodial care services 99324-99328, 99334-99337
Preventive medicine 99385-99387, 99395-99397, 99401-99404, 99411, 99412, 99420, 99429
G0402, G0438, G0439
Ophthalmology and optometry 92002, 92004, 92012, 92014 S0620, S0621
General medical examination V70.0, V70.3, V70.5, V70.6, V70.8, V70.9
Adolescent Well-Care Visits (ages 12-21) [Commercial, Medicaid]
Codes to identify Adolescent Well-Care Visits
CPT HCPCS ICD-9-CM Diagnosis
99383-99385, 99393-99395 G0438, G0439 V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9
Source: HEDIS 2013 Technical SpecificationsAllowable codes may vary by state. Reimbursement for these services will be per the terms of your agreement.
HEDIS Code Quick Reference Guide—Women’s Health Services
Insurance coverage provided by UnitedHealthcare Insurance Company or its affiliates. Health plan coverage provided by UnitedHealthcare of Arizona, Inc., UnitedHealthcare of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of Oregon, Inc., UnitedHealthcare of Utah, Inc. and UnitedHealthcare of Washington, Inc. or other affiliates. Administrative services provided by United HealthCare Services, Inc. or its affiliates.
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