CPT® Code Set →
section notes
Category II Codes →
section notes
Diagnostic/Screening Processes or Results →
section notes
3006F   CHEST X-RAY RESULTS DOCUMENTED & REVIEWED
3008F   BODY MASS INDEX DOCUMENTED
3011F   LIPID PANEL RESULTS DOCUMENTED & REVIEWED
3014F   SCREENING MAMMOGRAPHY RESULTS DOC&REV
3015F   CERVICAL CANCER SCREENING RESULTS DOCD & RVWD
3016F   PT SCRND UNHLTHY OH USE BY SYSTMTC SCRNG METHD
3017F   COLORECTAL CANCER SCREENING RESULTS DOC&REV
3018F   PRE-PRX RISK ASSESS DEPTH&QUAL BOWEL PREP
3019F   LVEF ASSESSMENT PLANNED POST DISCHARGE
3020F   LEFT VENTRICULAR FUNCTION ASSESSMENT DOCUMENTED
3021F   LEFT VENTRICULAR EJECTION FRACTION <40%
3022F   LEFT VENTRICULAR EJECTION FRACTION >= 40%
3023F   SPIROMETRY RESULTS DOCUMENTED AND REVIEWED
3025F   SPIROMETRY TEST RESULTS FEV/FVC <70% W/COPD
3027F   SPIROMETRY TEST RESULTS FEV/FVC >=70% W/O COPD
3028F   OXYGEN SATURATION RESULTS DOCUMENTED & REVIEWE
3035F   OXYGEN SATUR <= 88%/PAO2 <= 55 MM
3037F   OXYGEN SATURATION >88%/PAO2 >55 MM HG
3038F   PULMONARY FUNC TEST WITHIN 12 MON PRIOR SURG
3040F   FUNCTIONAL EXPIRATORY VOLUME < 40%
3042F   FUNCTJL EXPIR VOLUME >= 40% PREDICTED VALUE
3044F‑3052F   Most Recent Processes or Results
3055F   LVEF LESS THAN OR EQUAL TO 35%
3056F   LVEF GREATER THAN 35%
3060F   POSITIVE MICROALBUMINURIA TEST RESULT DOC&REV
3061F   NEGATIVE MICROALBUMINURIA TEST RESULT DOC&REV
3062F   POSITIVE MACROALBUMINURIA TEST RESULT DOC&REV
3066F   DOCUMENTATION OF TREATMENT FOR NEPHROPATHY
3072F   LOW RISK FOR RETINOPATHY
3073F   DOCUMENTED LENGTH CORNEAL POWER & LENS POWER
3074F   MOST RECENT SYSTOLIC BLOOD PRESSURE <130 MM HG
3075F   MOST RECENT SYSTOLIC BLOOD PRESS 130-139MM HG
3077F   MOST RECENT SYSTOLIC BLOOD PRES>= 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 DIASTOL BLOOD PRES >= 90 MM HG
3082F   KT/V <1.2 (CLEARANCE OF UREA (KT)/VOLUME (V))
3083F   KT/V EQUAL/>1.2 & <1.7
3084F   KT/V >= 1.7
3085F   SUICIDE RISK ASSESSED
3088F   MAJOR DEPRESSIVE DISORDER MILD
3089F   MAJOR DEPRESSIVE DISORDER MODERATE
3090F   MDD SEVERE WITHOUT PSYCHOTIC FEATURES
3091F   MAJOR DESPRESV DISORDER SEVERE W/PSYCHOT FEATURE
3092F   MAJOR DEPRESSIVE DISORDER REMISSION
3093F   DOC NEW DIAG DX INIT/RECURRENT EPISODE OF MDD
3095F   CENTRAL DUAL ENERGY ABSORPTIOMETRY DOCD
3096F   CENTRAL DUAL ENERGY ABSORPTIOMETRY ORDERED
3100F   CAROTID IMAGNG REPORT DIR/INDIR MEAS VESSEL DIAM
3110F   CT/MRI HMRHG/MASS LESION/ACUTE INFRC DOC
3111F   CT OR MRI BRAIN DONE W/IN 24 HRS HOSP ARRIVAL
3112F   CT/MRI BRAIN DONE 24 HRS AFTER HOSP ARRIVAL
3115F   QUANT RESULTS EVAL CURR LEVEL ACTIVITY CLIN SYMP
3117F   HF DISEASE SPECIFIC ASSESSMENT TOOL COMPLETED
3118F   NEW YORK HEART ASSOCIATION (NYHA) CLASS DOCD
3119F   NO EVAL LEVEL OF ACTIVITY OR CLINICAL SYMPTOMS
3120F   12-LEAD ECG PERFORMED
3126F   ESOPH BX RPRT W/DYSPLAS INFO AND APPROP GRADING
3130F   UPPER GI ENDOSCOPY PERFORMED
3132F   DOC REFERAL FOR UPPER GI ENDOSCOPY
3140F   UPPER GI ENDO REPORT SHOWS POSS BARRETT'S ESOPH
3141F   UPPER GI ENDO REPORT SHOW NO SUSPECT BARRETT'S
3142F   BARIUM SWALLOW TEST ORDERED
3150F   FORCEPS ESOPHAGEAL BIOPSY PERFORMED
3155F   CYTOGEN TEST DONE MARROW DIAG OR PRIOR TXMNT
3160F   DOC IRON STORES PRIOR START EPO THERAPY
3170F   BASELINE FLOW CYTOMETRY W/DIAG/PRIOR INITG TX
3200F   BARIUM SWALLOW TEST NOT ORDERED
3210F   GROUP A STREP TEST PERFORMED
3215F   DOCUMENTED IMMUNITY HEPATITIS A
3216F   DOCUMENTED IMMUNITY HEPATITIS B
3218F   HEP C RNA TEST 6 MOS BEFORE ANTIVIRAL TX
3220F   HEP C QUANT RNA TEST 12 WKS AFTER ANTIVIRAL TX
3230F   HEARING TEST 6 MOS PRIOR TO EAR TUBE INSERTION
3250F   NONPRIM ANATOMIC LOCATION OF SPECIMEN SITE
3260F   TUMOR/NODES/HISTO GRADE DOCUMENTED
3265F   RNA TESTING FOR HEP C VIREMIA ORDERED/DOCD
3266F   HEPATITIS C GENOTYPE PRIOR ANTIVIRAL TREATMENT
3267F   PATH RPRT INCLUDES PT & PN CAT GLEASON
3268F   PSA & TUMOR STAGE&GLEASON SCORE PRIOR INIT
3269F   BONE SCAN PRIOR INITIAT TX/DX PROSTATE CANCER
3270F   BONE SCAN NOT PRIOR INITIAT TX/DX PROSTATE CA
3271F   LOW RISK OF RECURRENCE PROSTATE CANCER
3272F   INTERMED RISK OF RECURRENCE PROSTATE CANCER
3273F   HIGH RISK OF RECURRENCE PROSTATE CANCER
3274F   PROST CANCER RSK RECUR NOT DETER/LOW/INTERMED/HI
3278F   SERUM LEVELS CALCUM PHOSPH PARATHYR & LIPID PR
3279F   HEMOGLOBIN LEVEL>= 13 G/DL
3280F   HEMOGLOBIN LEVEL 11 G/DL-12.9 G/DL
3281F   HEMOGLOBIN LEVEL <11 G/DL
3284F   IO PRESSURE REDUCED >= 15% PRE-INTERVENTION LVL
3285F   IOP REDUCED <15% PRE-INTERVENTION LEVEL
3288F   FALLS RISK ASSESSMENT DOCUMENTED
3290F   PATIENT IS D (RH) NEGATIVE AND UNSENSITIZED
3291F   PATIENT IS D (RH) POSITIVE OR SENSITIZED
3292F   HIV TSTNG ASK/DOCD/RVWD AT 1ST/2ND PRENATAL VST
3293F   ABO AND RH BLOOD TYPING DOCUMENTED AS PERFORMED
3294F   GBS SCRNING DOCD DONE DURING WK 35-37 GESTATION
3300F   AJCC STAGE DOCUMENTED & REVIEWED
3301F   CANCER STAGE DOCD METASTATIC & REVIEWED
3315F   ESTROGEN/PROGEST RECEPTOR POSITIVE BREAST CANCER
3316F   ESTROGEN/PROGEST RECEPTOR NEGATIVE BREAST CANCER
3317F   PATH REPRT MALIGNANCY DOCD & RVWD INITIATE CHE
3318F   PATH REPRT MALIGNANCY DOCD & RVWD INITIA RAD
3319F   1 DX IMG ORDER CHEST XRAY CT US MRI PET/NUC MED
3320F   0 DX IMG ORDER CHEST XRAY CT US MRI PET/NUC MED
3321F   AJCC CANCER STAGE 0 OR IA MELANOMA
3322F   MELANOMA THAN AJCC STAGE 0
3323F   CLIN TUMOR NODE METASTASES STAGE DOCD PRIOR SURG
3324F   MRI CT SCAN ORDERED REVIEWED/REQUESTED
3325F   PREOP ASSES 12 MOS PRIOR CATARACT SURG W/IO LENS
3328F   PERFORMANCE STATUS DOCD RVWD 2 WKS PRIOR SURG
3330F   IMAGING STUDY ORDERED
3331F   IMAGING STUDY NOT ORDERED
3340F   MAMMO ASSESSMENT CAT INCOMP ADDTNL IMAGE DOCD
3341F   MAMMO ASSESSMENT CAT NEGATIVE DOCD
3342F   MAMMO ASSESSMENT CAT BENIGN DOCD
3343F   MAMMO ASSESSMENT CAT PROB BENIGN DOCD
3344F   MAMMO ASSESSMENT CAT SUSPICIOUS DOCD
3345F   MAMMO ASSESSMENT CAT HIGH CHANCE MALIG DOCD
3350F   MAMMO ASSESSMENT CAT BIOPSY PROVEN MALIG DOCD
3351F   NEG DEP SYMP CAT USING STAND DEP ASSESS TOOL
3352F   NO SIGNIF DEP SYMP CAT BY STAND DEP ASSESS TOOL
3353F   MILD TO MOD DEP SYMP BY STAND DEP ASSESS TOOL
3354F   CLIN SIGN DEP SYMP BY STAND DEP ASSESS TOOL
3370F   AJCC BREAST CANCER STAGE 0 DOCUMENTED
3372F   AJCC BREAST CANCER STAGE I T1MIC T1A/T1B
3374F   AJCC BREAST CANCER STAGE I T1C
3376F   AJCC BREAST CANCER STAGE II
3378F   AJCC BREAST CANCER STAGE III
3380F   AJCC BREAST CANCER STAGE IV
3382F   AJCC COLON CANCER STAGE 0
3384F   AJCC COLON CANCER STAGE I
3386F   AJCC COLON CANCER STAGE II
3388F   AJCC COLON CANCER STAGE III DOCD
3390F   AJCC COLON CANCER STAGE IV DOCD
3394F   QUANT HER2 IHC EVAL OF BRST CANCER ASCO/CAP
3395F   QUANT NON-HER2 IHC EVAL OF BRST CANCER PERFORMED
3450F   DYSPNEA SCRND NO-MILD DYSPNEA
3451F   DYSPNEA SCRND MOD-SEVERE DYSPNEA
3452F   DYSPNEA NOT SCREENED
3455F   TB SCR PFRMD&INTRPD W/IN 6 MO INITIATION RA THER
3470F   RHEUMATOID ARTHRITIS (RA) DISEASE ACTIVITY LOW
3471F   RHEUMATOID ARTHRITIS (RA) DISEASE ACTIVITY MOD
3472F   RHEUMATOID ARTHRITIS (RA) DISEASE ACTIVITY HIGH
3475F   DISEASE PROGNOSIS RA ASSESSED POOR PROG DOCD
3476F   DISEASE PROGNOSIS RA ASSESSED GOOD PROG DOCD
3490F   HISTORY OF AIDS-DEFINING CONDITION
3491F   HIV INDETERMINATE INFANTS BORN OF HIV MOTHERS
3492F   HISTORY OF NADIR CD4+ CELL COUNT <350 CELLS/MM3
3493F   NO HIST NADIR CD4+ CELL CNT <350&AIDS CONDITION
3494F   CD4+ CELL COUNT <200 CELLS/MM
3495F   CD4+ CELL COUNT 200-499 CELLS/MM (HIV)
3496F   CD4+ CELL COUNT >= 500 CELLS/MM
3497F   CD4+ CELL PERCENTAGE <15% HIV
3498F   CD4+ CELL PERCENTAGE >= 15% HIV
3500F   CD4+CELL CNT/CD4+CELL % DOCD AS DONE
3502F   HIV RNA VIRAL LOAD
3503F   HIV RNA VIRAL LOAD NOT
3510F   DOCJ TB SCREEN PERFORMED & RESULTS INTERPRET
3511F   CHLAMYDIA/GONORRHEA TSTS DOCD AS DONE
3512F   SYPHILIS SCREENING DOCUMENTED AS DONE
3513F   HEPATITIS B SCREENING DOCUMENTED AS PERFORMED
3514F   HEPATITIS C SCREENING DOCUMENTED AS PERFORMED
3515F   PATIENT HAS DOCUMENTED IMMUNITY TO HEPATITIS C
3517F   HBV STATUS ASSESSED W/ RESULTS IN 1 YR
3520F   CLOSTRIDIUM DIFFICILE TESTING PERFORMED
3550F   LOW RISK FOR THROMBOEMBOLISM
3551F   INTERMEDIATE RISK FOR THROMBOEMBOLISM
3552F   HIGH RISK FOR THROMBOEMBOLISM
3555F   PT HAD INR MEASUREMENT PERFORMED
3570F   REPORT BONE SCINTIGRAPHY W/X-RAY SAME REGION
3572F   PT POTENTIAL RISK FRACTURE WEIGHT-BEARING SITE
3573F   PT NOT POTENT RISK FRACTURE WEIGHT-BEARING SITE
3650F   ELECTROENCEPHALOGRAM ORDERED RVWD OR REQ
3700F   PSYCHIATRIC DISORDERS/DISTURBANCES ASSESSED
3720F   COGNITIVE IMPAIRMENT/DYSFUNCTION ASSESSED
3725F   SCREENING FOR DEPRESSION PERFORMED
3750F   PT NOT RCVNG CORTICOSTERIDS>=10MG/DAY 60/> DAYS
3751F   ELECTRODIAG STUDIES DSP DOCD RVWD W/IN 6 MONTHS
3752F   ELECTRODIAG STUDIES DSP NOT DOCD RVWD W/IN 6 MON
3753F   PT HAS CLINICAL SYMP&SIGNS NEUROPATHY W/CAUSE
3754F   SCREENING TSTS DIABETES MELLITUS RVWD RQSTD ORD
3755F   COGNITIVE&BEHAVIORAL IMPAIRMENT SCRNG PERFORMED
3756F   PT HAS PSEUDOBULBAR AFFECT/SIALORRHEA/ALS SYMP
3757F   NO PSEUDOBULBAR AFFECT/SIALORRHEA/ALS SYMP
3758F   PULM FUNC TESTING/PEAK COUGH EXPIRATORY FLOW
3759F   PT SCRND DYSPHAGIA WT LOSS IMPAIRED NUTRITION
3760F   PT W/DYSPHAG/WT LOSS/IMPAIRED NUTRITION
3761F   PT WO/DYSPHAG/WT LOSS/IMPAIRED NUTRITION
3762F   PATIENT IS DYSARTHRIC
3763F   PATIENT IS NOT DYSARTHRIC
3775F   ADENOMA(S)/NEOPLASM DETECTED SCRNG CLNSCPY
3776F   ADENOMA(S)/NEOPLASM NOT DETECTED SCRNG CLNSCPY
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