CPT® Code Set →
section notes
Category II Codes →
section notes
Patient History →
section notes
1000F   TOBACCO USE ASSESSED
1002F   ANGINAL SYMPTOMS & LEVEL ACTIVITY ASSESSED
1003F   LEVEL ACTIVITY ASSESSED
1004F   CLINICAL SYMPTOMS VOL OVERLOAD ASSESSED
1005F   ASTHMA SYMPTOMS EVALUATED
1006F   OSTEOARTHRITIS SYMPTOMS&FUNCJAL STATUS ASSES
1007F   ANTI-INFLAMMATORY/ANALGESIC SYMPTOM RELIEF ASSES
1008F   GI&RENAL PRESCRIBED/OTC NSAID RISK FACTORS ASSES
1010F   SEVERITY OF ANGINA ASSESSED BY LEVEL OF ACTIVITY
1011F   ANGINA PRESENT
1012F   ANGINA ABSENT
1015F   COPD SYMPTOMS ASSESSED/TOOL COMPLETED
1018F   DYSPNEA ASSESSED NOT PRESENT
1019F   DYSPNEA ASSESSED PRESENT
1022F   PNEUMOCOCCUS IMMUNIZATION STATUS ASSESSED
1026F   CO-MORBID CONDITIONS ASSESSED
1030F   INFLUENZA IMMUNIZATION STATUS ASSESSED
1031F   SMOKING & 2ND HAND SMOKE IN THE HOME ASSESSED
1032F   CURRENT SMOKER/EXPOSED TO SECONDHAND SMOKE
1033F   TOBACCO NON-SMOKER & NO 2NDHAND SMOKE EXPOSURE
1034F   CURRENT TOBACCO SMOKER
1035F   CURRENT SMOKELESS TOBACCO USER
1036F   CURRENT TOBACCO NON-USER CAD CAP COPD PV DM
1038F   PERSISTENT ASTHMA MILD MODERATE OR SEVERE ASTHMA
1039F   INTERMITTENT ASTHMA
1040F   DSM-5 CRITERIA MDD DOCD AT THE INITIAL EVAL
1050F   HISTORY NEW OR CHANGING MOLES
1052F   TYPE ANATOMIC LOCATION AND ACTIVITY ALL ASSESSED
1055F   VISUAL FUNCTIONAL STATUS ASSESSED
1060F   DOC PERM/PERSISTENT/PAROXYSMAL ATRIAL FIB
1061F   DOC ABSENCE PERM&PERSISTENT&PAROXYSM ATRIAL FIB
1065F   ISCHEMIC STROKE SYMP ONSET <3 HRS PRIOR ARRIVAL
1066F   ISCHEMIC STROKE SX ONSET >=3 HRS PRIOR ARRIVAL
1070F‑1071F   Alarm symptoms (involuntary weight loss, dysphagia, or gastrointestinal bleeding) assessed
1090F   PRESENCE/ABSENCE URINARY INCONTINENCE ASSESSED
1091F   URINE INCONTINENCE CHARACTERIZED
1100F‑1101F   Patient screened for future fall risk
1110F   PT DISCHARGE INPT FACILITY WITHIN LAST 60 DAYS
1111F   DISCHRG MEDS RECONCILED W/CURRENT MED LIST
1116F   AURICULAR/PERIAURICULAR PAIN ASSESSED
1118F   GERD SYMPTOMS ASSESSED AFTER 12 MONTHS THERAPY
1119F   INITIAL EVALUATION FOR CONDITION
1121F   SUBSEQUENT EVALUATION CONDITION
1123F‑1124F   Advance Care Planning discussed and documented in the medical record (DEM) (GER, Pall Cr)
1125F‑1126F   Pain severity quantified
1127F   NEW EPISODE FOR CONDITION
1128F   SUBS EPISODE FOR CONDITION
1130F   BK PAIN & FXN ASSESSED CERTAIN ASPECTS OF CARE
1134F   EPISODE BACK PAIN LASTING SIX WEEKS/<
1135F   EPISODE BACK PAIN LASTING >SIX WEEKS
1136F   EPISODE BACK PAIN LASTING 12 WEEKS/<
1137F   EPISODE BACK PAIN LASTING >12 WKS
1150F   DOC PT W/SUBSTANTIAL RISK DEATH WITHIN 1 YEAR
1151F   DOC PT W/O SUBSTANTIAL RISK DEATH WITHIN 1 YEAR
1152F   DOC ADVANCED DISEASE DX CARE GOALS COMFORT
1153F   DOC ADVANCED DISEASE DX CARE GOALS W/O COMFORT
1157F   ADVNC CARE PLAN OR EQV LGL DOC IN MED RCRD
1158F   ADVNC CARE PLANNING TLK DOCD IN MED RCRD
1159F   MEDICATION LIST DOCUMENTED IN MEDICAL RECORD
1160F   RVW ALL MEDS BY RXNG PRCTIONR OR CLIN RPH DOCD
1170F   FUNCTIONAL STATUS ASSESSED
1175F   FUNCTIONAL STATUS DEMENTIA ASSESS RESULTS RVWD
1180F   THROMBOEMBOLIC RISK ASSESSED
1181F   NEUROPSYCHIATRIC SYMPTS ASSESSED RESULTS REVIEWD
1182F   NEUROPSYCHIATRIC SYMPTOMS ONE OR MORE PRESENT
1183F   NEUROPSYCHIATRIC SYMPTOMS ABSENT
1200F   SEIZURE TYPE FREQUENCY DOCUMENTED
1205F   ETIOLOGY OF EPILEPSY SYNDROME RVWD & DOCD
1220F   PATIENT SCREENED DEPRESSION
1400F   PARKINSON DISEASE DIAGNOSIS REVIEWED
1450F   SYMPTOMS IMPROVED/CONSIST W/TXMNT GOAL ASSESSMNT
1451F   SYMPTOMS SHOW CLIN IMPRTNT DROP SINCE ASSESSMENT
1460F   QUALIFYING CARD EVENT/DIAGNOSIS PRIOR 12 MONTHS
1461F   NO QUAL CARD EVENT/DIAG IN PREVIOUS 12 MONTHS
1490F‑1493F   Dementia severity classified
1494F   COGNITION ASSESSED AND REVIEWED
1500F   SYMP&SIGN DISTAL SYMM POLYNEUROPATHY REVWD&DOCD
1501F   NOT INITIAL EVALUATION FOR CONDITION
1502F   PT QUERIED RE PAIN W/FUNC USING RELIABLE INSTRM
1503F   PT QUERIED RE SYMP RESPIRATORY INSUFFICIENCY
1504F   PATIENT HAS RESPIRATORY INSUFFICIENCY
1505F   PATIENT DOES NOT HAVE RESPIRATORY INSUFFICIENCY
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