BCBSM/BCN Dual Header The Record Header Logo

The Record - Insurance Card with the BCBSM/BCN Cross and Shield logo that reads, Blue Cross Blue Shield, Blue Care Network of Michigan. Tagline: Confidence comes with every card. Image of Note boards with paper that has the letters RX on it accompanied by a stethoscope

Forward to a friend  |  Subscribe  |  The Record Archive  |  Contacts  |  bcbsm.com  |  Print this article
July 2018

Improve HEDIS scores, reduce medical record requests through proper claims coding

Submitting claims with CPT® Category II and ICD-10 codes can help Blue Cross Blue Shield of Michigan determine if certain HEDIS® measures are met without needing to review medical records. This lessens the administrative burden on office staff because it reduces the need for them to pull medical records for Blue Cross’ review.

CPT II codes that support select HEDIS measures include:

HEDIS measure

CPT II code

Description

Medication reconciliation post discharge

*1111F

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

Comprehensive diabetes care - eye exam
(The patient’s eye exam report must be included in your medical record).

*2022F

Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed

*3072F

Low risk for retinopathy (no evidence of retinopathy in the prior year)

Comprehensive diabetes care - HbA1c control

*3044F

Most recent HbA1c level < 7.0%

*3045F

Most recent HbA1c level 7.0-9.0%

*3046F

Most recent HbA1c level > 9.0%

Comprehensive diabetes care - medical attention for nephropathy

*3066F

Documentation of treatment for nephropathy (includes visit to nephrologist, receiving dialysis, treatment for end stage renal disease, chronic renal failure, acute renal failure or renal insufficiency)

*4010F

Angiotensin converting enzyme inhibitor or angiotensin receptor blocker therapy prescribed or currently being taken

Comprehensive diabetes care - blood pressure control

and

Controlling high blood pressure**

*3074F

Most recent systolic blood pressure <130 mm Hg

*3075F

Most recent systolic blood pressure 130 – 139 mm Hg

*3077F

Most recent systolic blood pressure > 140 mm Hg

*3078F

Most recent diastolic blood pressure <80 mm Hg

*3079F

Most recent diastolic blood pressure 80 – 89 mm Hg

*3080F

Most recent diastolic blood pressure > 90 mm Hg

**The National Committee for Quality Assurance requires medical record review for the controlling high blood pressure measure. However, for the comprehensive diabetes care – blood pressure control measure, CPT Category II codes can be used to identify compliant members through claims data when the member’s latest blood pressure reading is compliant (<140/90).

ICD-10 codes that support HEDIS exclusion criteria include:

Patients will not be identified for certain HEDIS measures when ICD-10 exclusion codes are submitted on a claim. These include:

Measure

ICD-10 code

Description

Breast cancer screening
Patients who have bilateral or two unilateral mastectomies

Z90.13

Acquired absence of bilateral breasts and nipples

Z90.12

Acquired absence of left breast and nipple

Z90.11

Acquired absence of right breast and nipple

Colorectal cancer screening
Patients who currently have or with a history of colorectal cancer. (Cancer of the small intestine doesn’t count.)

Z85.038

Personal history of other malignant neoplasm of large intestine

Z85.048

Personal history of other malignant neoplasm of rectum, rectosigmoid junction and anus

ICD-10 codes that support the adult BMI assessment measure include:

HEDIS measure

ICD-10 code

Description

Adult BMI

Z68.1

BMI of 19.99 or less

Z68.20

BMI 20.0-20.9

Z68.21

BMI 21.0-21.9

Z68.22

BMI 22.0-22.9

Z68.23

BMI 23.0-23.9

Z68.24

BMI 24.0-24.9

Z68.25

BMI 25.0-25.9

Z68.26

BMI 26.0-26.9

Z68.27

BMI 27.0-27.9

Z68.28

BMI 28.0-28.9

Z68.29

BMI 29.0-29.9

Z68.30

BMI 30.0-30.9

Z68.31

BMI 31.0-31.9

Z68.32

BMI 32.0-32.9

Z68.33

BMI 33.0-33.9

Z68.34

BMI 34.0-34.9

Z68.35

BMI 35.0-35.9

Z68.36

BMI 36.0-36.9

Z68.37

BMI 37.0-37.9

Z68.38

BMI 38.0-38.9

Z68.39

BMI 39.0-39.9

Z68.41

BMI 40.0-44.9

Z68.42

BMI 45.0-49.9

Z68.43

BMI 50.0-59.9

Z68.44

BMI 60.0-69.9

 

Z68.45

BMI 70.0 or greater

For more information on HEDIS measures, see our Clinical Quality Corner tip sheets. An article in this issue explains how to access them on web-DENIS.

HEDIS® is a registered trademark of the National Committee for Quality Assurance.

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2017 American Medical Association. All rights reserved.
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and
independent licensees of the Blue Cross and Blue Shield Association.