Category II Code Question


Hagerstown, MD
Best answers
Anyone using the Codes 3078F, 3079F, 3080F, and 3074F, 3075F, 3077F? My understanding is that these codes required documentation of controlled BP for a patient with a dx of HTN or CKD or CAD or DM. (Per the description of the numerators/denominator on the AMA-ASSN.ORG website.) Is this correct? I am in discussion with others in my department that are under the assumption that these codes can be reported based upon the BP being recorded/reviewed and that a specific condition is not required.
No, these codes can be reported for any patient. You want to always include them for your hypertensive patients, because this gap will re-open on each visit.
For Risk Adjustment purposes, 3078F-3077F serves no purpose in code validation as they are not ICD-10 codes.
Basically, these codes are used to identify whether patient's specified medical condition is adequately controlled. For HEDIS purpose, and to be measure complaint, as per guideline, for HTN, age between 18-85, BP <140/90; for DM, age between 18-75, HgA1C < 9%. In terms to close the gap, it should be reported at least one "adequately controlled readings" twice a year - i.e. one reports between Jan and Jun then one reports between Jul and Dec. And these category II codes are triggered by the related dx, i.e. HTN and DM, so patient does not have either medical condition, insurance is not going to require these code to be reported.