CPT® Code Set →
section notes
Category II Codes →
section notes
Therapeutic, Preventive or Other Interventions →
section notes
4000F   TOBACCO USE CESSATION IVNTJ COUNSELING
4001F   TOBACCO USE CESSATION IVNTJ PHARMACOLOGIC THER
4003F   PT EDUCATION WRTTN/ORAL HRT FAILURE PTS PFRMD
4004F   PT SCRND TOBACCO USE RCVD TOBACCO CESSATION TALK
4005F   PHARMACOLOGIC OSTEOPOROSIS THERAPY PRESCRIBED
4008F   BETA BLOCKER THERAPY RXD/CURRENTLY BEING TAKEN
4010F   ACE INHIBITOR/ARB THERAPY RXD/CURRENTLY TAKEN
4011F   ORAL ANTIPLATELET THERAPY PRESCRIBED
4012F   WARFARIN THERAPY PRESCRIBED
4013F   STATIN THERAPY RXD/CURRENTLY TAKEN
4014F   DSCHRG INSTRUCTIONS HRT FAILURE XCP PTS 18 YR
4015F   PRSISTENT ASTHMA LONG TERM CTRL MED PRESCRIBED
4016F   ANTI-INFLAMMATORY/ANALGESIC AGT PRESCRIBED
4017F   GI PROPHYLAXIS NSAID USE PRESCRIBED
4018F   THERAPEUTIC EXERCISE INVOLVED JTS INST/PRESCRIBE
4019F   DOCUMENT COUNSELING EXERCISE CALCIUM & VITAMIN
4025F   INHALED BRONCHODILATOR PRESCRIBED
4030F   LONG-TERM OXYGEN THERAPY PRESCRIBED
4033F   PULMONARY REHABILITATION RECOMMENDED
4035F   INFLUENZA IMMUNIZATION RECOMMENDED
4037F   INFLUENZA IMMUNIZATION ORDERED OR ADMINISTERED
4040F   PNEUMOCOCCAL VACCINE ADMIN RCVD PRIOR
4041F   DOC ORDER CEFAZOLIN/CEFUROXIME ANTIMICRB PROPHYL
4042F   DOC PROPHY ANTIBIO NOT GIVEN W/IN 4 HR PRIOR SUR
4043F   DOC ORDER DISCONT ANTIBIO W/IN 48 HOURS OF SURG
4044F   DOC ORDER VTE PROPHYL W/IN 24 HRS PRIOR SURG
4045F   APPROPRIATE EMPIRIC ANTIBIOTIC PRESCRIBED
4046F   DOCD ANTIBIO W/IN 4 HRS PRIOR/INTRAOP SURG INCIS
4047F   DOC ORDER ANTIBIO GIVEN W/IN 1 HR PRIOR SURG/INC
4048F   DOC ANTIBIO GIVEN W/IN 1 HR PRIOR SURG/INCIS
4049F   DOC ORDER GIVEN TO STOP ANTIBIO W/IN 24 HRS SURG
4050F   HYPERTENSION PLAN OF CARE DOCUMENTED
4051F   REFERRED FOR AN ARTERIO-VENOUS (AV) FISTULA
4052F   HEMODIAL VIA FUNCTIONG AV FISTULA
4053F   HEMODIALYSIS VIA FUNCTIONING AVGRAFT
4054F   HEMODIALYSIS VIA CATHETER
4055F   PATIENT RECEIVING PERITONEAL DIALYSIS
4056F   APPROPRIATE ORAL REHYD SOLUTION RECOMMENDED
4058F   PAG PROVIDED TO CAREGIVER
4060F   PSYCHOTHERAPY SERVICES PROVIDED
4062F   PATIENT REFERRAL FOR PSYCHOTHERAPY DOCUMENTED
4063F   ANTIDEPRESSANT RXTHXY CONSIDER & NOT PRESCRIBE
4064F   ANTIDEPRESSANT PHARMACOTHERAPY PRESCRIBED
4065F   ANTIPSYCHOTIC PHARMACOTHERAPY PRESCRIBED
4066F   ELECTROCONVULSIVE THERAPY (ECT) PROVIDED
4067F   PT REFERRAL ELECTROCONVULSIVE THXPY (ECT) DOCD
4069F   VENOUS THROMBOEMBOLISM (VTE) PROPHYLAXIS RCVD
4070F   DEEP VEIN THROMB PROPHYL RECVD BY HOSP DAY 2
4073F   ORAL ANTIPLATELET THERAPY PRESCRBED AT DISCHARGE
4075F   ANTICOAGULANT THERAPY PRESCRIBED AT DISCHARGE
4077F   DOC T-PA ADMINISTRATION WAS CONSIDERED
4079F   DOC REHAB SERVICES WERE CONSIDERED
4084F   ASPIRIN RECVD W/IN 24 HRS PRIOR ED ARRIVAL/STAY
4086F   ASPIRIN OR CLOPIDOGREL PRESCRIBED
4090F   PATIENT RECEIVING ERYTHROPOIETIN THERAPY
4095F   PATIENT NOT RECEIVING ERYTHORPOIETIN THERAPY
4100F   BISPHOS THXPY VENOUS ORDERED OR RECEIVED
4110F   LIMA GRAFT USED IN 1ST ISOLATED CABG PXD
4115F   BETA BLOCKER GIVEN W/IN 24 HRS PRIOR SURG INC
4120F   ANTIBIOTIC PRESCRIBED OR DISPENSED
4124F   ANTIBIOTIC NEITHER PRESCRIBED NOR DISPENSED
4130F   ACUTE OTITIS EXTERNA TOPICAL PREPS PRESCRIBED
4131F   SYSTEMIC ANTIMICROBIAL TX PRESCRIBED
4132F   SYSTEMIC ANTIMICROBIAL TX NOT PRESCRIBED
4133F   ANTIHISTAMINE/DECONGESTANT PRESCRIBED
4134F   ANTIHISTAMINE/DECONGESTANT NOT PRESCRIBED
4135F   SYSTEMIC CORTICOSTEROIDS PRESCRIBED
4136F   SYSTEMIC CORTICOSTEROIDS NOT PRESCRIBED
4140F   INHALED CORTICOSTEROIDS PRESCRIBED
4142F   CORTICOSTEROID SPARING THERAPY PRESCRIBED
4144F   ALTERNATIVE LONG-TERM CONTROL MEDICATION RXD
4145F   2+ ANTI-HYPERTENSIVE AGENTS RXD OR TAKEN
4148F   HEPATITIS A VACCINE ADMIN OR PREVIOSLY RECVD
4149F   HEPATITIS B VACCCINE ADMIN OR PREVIOSLY RECVD
4150F   CURRENT HEPATITIS C ANTIVIRAL TREATMENT
4151F   NO CURRENT HEPATITIS C ANTIVIRAL TREATMENT
4153F   COMB PEGINTERF/RIBAVIRIN TX PRESCRIBED
4155F   HEPATITIS A VACCINE SERIES PREVIOUSLY RECEIVED
4157F   HEPATITIS B VACCINE SERIES PREVIOUSLY RECEIVED
4158F   PATIENT COUNSELED ABOUT RISKS ALCOHOL USE
4159F   CONTRACEPTION COUNSEL BEFORE ANTIVIRAL TX
4163F   PT COUNSELING TREATMENT OPTIONS PROSTATE CANCER
4164F   ADJUVANT HORMONAL THXPY RX/ADMIN
4165F   3D-CRT OR INTENSITY MODUL RAD THXPY RECVD
4167F   HEAD-BED ELEV 30-45 DEG 1ST VENT DAY ORDERED
4168F   PT RCVG CARE ICU & RCVNG MECH VENT 24 HRS/<
4169F   PT NOT RCVG CARE IN ICU/NOT RCVG MECHL VENT
4171F   PATIENT RECEIVING (ESA) THERAPY
4172F   PATIENT NOT RECEIVING (ESA) THERAPY
4174F   TLK VIS FXN & QUAL LIFE/TRXMNT FOR PT/CRGVR
4175F   CORRECT VISUAL ACUIT 20/40/> W/IN 90 DAYS SURG
4176F   COUNSEL UV LITE PROTEC PREV/PROG CATARACT DEVEL
4177F   COUNSEL BENEF/RISK AREDS PREV AGE RELATED AMD
4178F   ANTI-D IMMUNE GLOBULIN RCVD 26-30 WKS GESTATION
4179F   TAMOXIFEN OR AROMATASE INHIBITOR (AI) RXD
4180F   ADJVNT CHEMO RFRRD RXD/RCVD STAGE III COLON CA
4181F   CONFORMAL RADIATION THERAPY RECEIVED
4182F   CONFORMAL RADIATION THERAPY NOT RECEIVED
4185F   NONSTOP 12MON THXPY W/PPI OR H2 H2RA RCVD
4186F   NO CONTIN 12MON THXPY W/PPI OR H2 H2RA RCVD
4187F   DIS MODFY ANTI-RHEU DRUG THXPY RX/GVN
4188F   APPROP ACE/ARB THXP MONIT TEST ORDRD/DONE
4189F   APPROP DIGOXIN THXP MONIT TST ORDRD/DONE
4190F   APPROP DIURETIC THXP MONIT TST ORDRD/DONE
4191F   APPROP ANTICONVUL THXP MONIT TST ORDRD/DONE
4192F   PATIENT NOT RECEIVING GLUCOCORTICOID
4193F   PATIENT RCVNG <10 MG DAILY PREDNISONE
4194F   PATIENT RCVNG >= 10 MG DAILY PREDNISONE
4195F   PT RCVNG 1ST BIOL ANTI-RHEUM DRUG THXRPY FOR RA
4196F   PT NOT RCVNG 1ST BIOL ANTI-RHEUM DRUG THXPY RA
4200F   EXTRNL BM RADIOTHXPY TO PROST W/WO NODAL IRRAD
4201F   EXTRNL BM RADIOTHXPY W/WO NODAL IRRAD AS ADJV
4210F   ACE/ARB MEDICATION THERAPY 6 MONTHS/>
4220F   DIGOXIN MEDICATION THERAPY 6 MONTHS/>
4221F   DIURETIC MEDICATION THERAPY 6 MOS/>
4230F   ANTICONVUL MED THERAPY 6 MOS/>
4240F   INSTR THER XRCS-DR FLLWUP PT EPSD BACK PN >12 WK
4242F   TLK RE SPRVSD XRCS PROG TO PTS BACK PN >12WKS
4245F   PT TLK 1ST VST TO KEEP/RESUME NORMAL ACTIVITIES
4248F   COUNSEL INIT BACK PAIN AGNST BED REST 4 DAYS/>
4250F   ACTV WRMNG INTRAOP FOR NORMOTHERMIA
4255F   DURATION GEN NEUR ANESTH 60 MINS/> DOC RECORD
4256F   DURATION GEN NEUR ANESTH <60 MIN DOCD RECORD
4260F   WOUND SURFACE CULTURE TECHNIQUE USED
4261F   TECH OTHER THAN SURFACE CULTURE WOUND EXUD USED
4265F   USE OF WET TO DRY DRESSINGS PRESCRIBED RECMD
4266F   USE WET TO DRY DRESSINGS NEITHER RXD NOR RECMD
4267F   COMPRESSION THERAPY PRESCRIBED
4268F   PT ED RE NEED LONG TERM COMPRESS THXPY RCVD
4269F   APPROP METHOD OFFLOADING PRESCRIBED
4270F   PT RCVNG POTENT ANTI R-VIRAL THX 6 MON OR MORE
4271F   PT RCVNG POT ANTI R-VIRAL THX <6 MON/NOT RCVN
4274F   FLU IMMUNO ADMIND/PREVIOUSLY RCVD
4276F   POTENT ANTIRETROVIRAL THERAPY PRESCRIBED
4279F   PNEUMOCYSTIS JIROVECI PNEUMONIA PROPHYLAXIS RXD
4280F   PNEUMOCYS JIROVECI PNEUMO PRPHYLXS PRSCRBD 3 MON
4290F   PATIENT SCREENED FOR INJECTION DRUG USE
4293F   PT SCRND HGH-RSK SEXUAL BEHAVIOR
4300F   PT RCVNG WARFARIN THXPY NONVALV AFIB OR AFLUT
4301F   PT NOT RCVNG WARFARIN THXPY NONVALV AFIB/AFLUT
4305F   PT EDUC FOOT CARE & DAILY INSPCTN FEET RCVD
4306F   PT COUNSEL PSYCHOSOC&PHARM TX OPIOID ADDICTION
4320F   PT COUNSEL PSYCHSOC & PHARM TX ALCOHOL DEPEND
4322F   CRGVR PROVIDED W/ED REFERRED ADDL RESOURCES
4324F   PT QUERIED PARKINSONS MED-RELATED COMPLICATION
4325F   MEDICAL & SURGICAL TREATMENT OPTION REVIEW W/P
4326F   PT/CAREGIVER QUERIED AUTONOMIC DYSFUNCJ SYMPTOMS
4328F   PT/CAREGIVER QUERIED SLEEP DISTURBANCES
4330F   EPILEPSY SPECIFIC SAFETY COUNSELING TO PATIENT
4340F   COUNSEL WOMEN CHILDBEARING POTENTIAL W/EPILEPSY
4350F   COUNSELING PROVIDED SYMP MNGMNT PALLIATION
4400F   REHAB THERAPY OPTIONS DISCUSSED W/PATIENT
4450F   SELF-CARE EDUCATION PROVIDED TO PATIENT
4470F   IMPLANT CARDIOVERT-DEFIB (ICD) COUNSELING PROV
4480F   PT RCVNG ACE/ARB BETA BLOCKER TX 3 MONS/LONGER
4481F   PT RCVNG ACE/ARB AND BETA BLOCKER < 3 MONTHS
4500F   REFERRED TO OUTPT CARD REHABILITATION PROGRAM
4510F   PREVIOUS CARDIAC REHAB FOR QUAL CARD EVENT DONE
4525F   NEUROPSYCHIATRIC INTERVENTION ORDERED
4526F   NEUROPSYCHIATRIC INTERVENTION RECEIVED
4540F   DISEASE MODIFYING PHARMACOTHERAPY DISCUSSED
4541F   TX PSEUDOBULBAR AFFECT SIALORRHEA/ALS SYMP
4550F   OPTIONS NONINVASIVE RESP SUPPORT DISCUSSED W/PT
4551F   NUTRITIONAL SUPPORT OFFERED
4552F   PT OFFERED REFERRAL SPEECH LANGUAGE PATHOLOGIST
4553F   PT OFFERED ASSISTANCE PLANNING END LIFE ISSUES
4554F   PT RECEIVED INHALATIONAL ANESTHETIC AGENT
4555F   PT DID NOT RECEIVE INHALATIONAL ANESTHETIC AGENT
4556F   PT SHOWS 3+RISK FACTORS POST-OP NAUSEA&VOMITING
4557F   PT NO EXHIBIT 3+ RISK FACTORS POST-OP NAUSEA/VOM
4558F   PT RCEVD 2 PROPHYLACTIC RX AGENTS PRE&INTRA-OP
4559F   1BODY TEMP MEAS>=35.5C IN 30-15 MINS POST ANESTH
4560F   ANESTH DID NOT INVOLVE GENERAL/NEURAXIAL ANESTH
4561F   PATIENT HAS A CORONARY ARTERY STENT
4562F   PATIENT DOES NOT HAVE A CORONARY ARTERY STENT
4563F   PT RECVD ASPIRIN W/IN 24 HRS PRIOR ANESTH START
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