Office Visit

CPT:
Code	Description
99201	Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.
99202	Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.
99203	Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter.
99204	Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter.
99205	Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 60-74 minutes of total time is spent on the date of the encounter.
99212	Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter.
99213	Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.
99214	Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter.
99215	Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.

 

SNOMED:
Code	Description
185463005	Visit out of hours (procedure)
185464004	Out of hours visit – not night visit (procedure)
185465003	Weekend visit (procedure)
30346009	Evaluation and management of established outpatient in office or other outpatient facility (procedure)
3391000175108	Office visit for pediatric care and assessment (procedure)
37894004	Evaluation and management of new outpatient in office or other outpatient facility (procedure)
439740005	Postoperative follow-up visit (procedure)

Telephone Visits

CPT:
Code	Description
98966	Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion
98967	Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion
98968	Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion
99441	Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion
99442	Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion
99443	Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion

 

SNOMED:
Code	Description
185317003	Telephone encounter (procedure)
314849005	Telephone contact by consultant (procedure)
386472008	Telephone consultation (procedure)
386473003	Telephone follow-up (procedure)
401267002	Telephone triage encounter (procedure)

Online Assessment

CPT:
Code	Description
98969	Online assessment and management service provided by a qualified nonphysician health care professional to an established patient or guardian, not originating from a related assessment and management service provided within the previous 7 days, using the Internet or similar electronic communications network
98970	Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes
98971	Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes
98972	Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes
98980	Remote therapeutic monitoring treatment management services, physician or other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient or caregiver during the calendar month; first 20 minutes
98981	Remote therapeutic monitoring treatment management services, physician or other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient or caregiver during the calendar month; each additional 20 minutes (List separately in addition to code for primary procedure)
99421	Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes
99422	Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes
99423	Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes
99444	Online evaluation and management service provided by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient or guardian, not originating from a related E/M service provided within the previous 7 days, using the Internet or similar electronic communications network
99457	Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; first 20 minutes
99458	Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; each additional 20 minutes (List separately in addition to code for primary procedure)

 

HCPCS:
Code	Description
G0071	Payment for communication technology-based services for 5 minutes or more of a virtual (non-face-to-face) communication between an rural health clinic (rhc) or federally qualified health center (fqhc) practitioner and rhc or fqhc patient, or 5 minutes or more of remote evaluation of recorded video and/or images by an rhc or fqhc practitioner, occurring in lieu of an office visit; rhc or fqhc only
G2010	Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment
G2012	Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion
G2061	Qualified nonphysician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 5-10 minutes
G2062	Qualified nonphysician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 11-20 minutes
G2063	Qualified nonphysician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 21 or more minutes
G2250	Remote assessment of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related service provided within the previous 7 days nor leading to a service or procedure within the next 24 hours or soonest available appointment
G2251	Brief communication technology-based service, e.g. virtual check-in, by a qualified health care professional who cannot report evaluation and management services, provided to an established patient, not originating from a related service provided within the previous 7 days nor leading to a service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of clinical discussion
G2252	Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion

Office Visit

CPT:
Code	Description
99201	Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.
99202	Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.
99203	Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter.
99204	Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter.
99205	Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 60-74 minutes of total time is spent on the date of the encounter.
99212	Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter.
99213	Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.
99214	Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter.
99215	Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.

 

SNOMED:
Code	Description
185463005	Visit out of hours (procedure)
185464004	Out of hours visit – not night visit (procedure)
185465003	Weekend visit (procedure)
30346009	Evaluation and management of established outpatient in office or other outpatient facility (procedure)
3391000175108	Office visit for pediatric care and assessment (procedure)
37894004	Evaluation and management of new outpatient in office or other outpatient facility (procedure)
439740005	Postoperative follow-up visit (procedure)

Telephone Visits

CPT:
Code	Description
98966	Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion
98967	Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion
98968	Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion
99441	Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion
99442	Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion
99443	Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion

 

SNOMED:
Code	Description
185317003	Telephone encounter (procedure)
314849005	Telephone contact by consultant (procedure)
386472008	Telephone consultation (procedure)
386473003	Telephone follow-up (procedure)
401267002	Telephone triage encounter (procedure)

Online Assessment

CPT:
Code	Description
98969	Online assessment and management service provided by a qualified nonphysician health care professional to an established patient or guardian, not originating from a related assessment and management service provided within the previous 7 days, using the Internet or similar electronic communications network
98970	Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes
98971	Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes
98972	Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes
98980	Remote therapeutic monitoring treatment management services, physician or other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient or caregiver during the calendar month; first 20 minutes
98981	Remote therapeutic monitoring treatment management services, physician or other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient or caregiver during the calendar month; each additional 20 minutes (List separately in addition to code for primary procedure)
99421	Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes
99422	Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes
99423	Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes
99444	Online evaluation and management service provided by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient or guardian, not originating from a related E/M service provided within the previous 7 days, using the Internet or similar electronic communications network
99457	Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; first 20 minutes
99458	Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; each additional 20 minutes (List separately in addition to code for primary procedure)

 

HCPCS:
Code	Description
G0071	Payment for communication technology-based services for 5 minutes or more of a virtual (non-face-to-face) communication between an rural health clinic (rhc) or federally qualified health center (fqhc) practitioner and rhc or fqhc patient, or 5 minutes or more of remote evaluation of recorded video and/or images by an rhc or fqhc practitioner, occurring in lieu of an office visit; rhc or fqhc only
G2010	Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment
G2012	Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion
G2061	Qualified nonphysician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 5-10 minutes
G2062	Qualified nonphysician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 11-20 minutes
G2063	Qualified nonphysician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 21 or more minutes
G2250	Remote assessment of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related service provided within the previous 7 days nor leading to a service or procedure within the next 24 hours or soonest available appointment
G2251	Brief communication technology-based service, e.g. virtual check-in, by a qualified health care professional who cannot report evaluation and management services, provided to an established patient, not originating from a related service provided within the previous 7 days nor leading to a service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of clinical discussion
G2252	Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion

Heart Failure

This is captured by adding a diagnosis with a valid SNOMED or ICD10 code using the Diagnosis widget in a note.

SNOMED:
Code	Description
10091002	High output heart failure (disorder)
101281000119107	Congestive heart failure due to cardiomyopathy (disorder)
10633002	Acute congestive heart failure (disorder)
111283005	Chronic left-sided heart failure (disorder)
1204200007	Left ventricular failure with normal ejection fraction due to valvular heart disease (disorder)
1204203009	Left ventricular failure with normal ejection fraction due to coronary arteriosclerosis (disorder)
1204204003	Left ventricular failure with normal ejection fraction due to myocarditis (disorder)
1204206001	Left ventricular failure with normal ejection fraction due to cardiomyopathy (disorder)
1204462004	Left ventricular failure with sepsis (disorder)
120851000119104	Systolic heart failure stage D (disorder)
120861000119102	Systolic heart failure stage C (disorder)
120871000119108	Systolic heart failure stage B (disorder)
120881000119106	Diastolic heart failure stage D (disorder)
120891000119109	Diastolic heart failure stage C (disorder)
120901000119108	Diastolic heart failure stage B (disorder)
153931000119109	Acute combined systolic and diastolic heart failure (disorder)
153941000119100	Chronic combined systolic and diastolic heart failure (disorder)
153951000119103	Acute on chronic combined systolic and diastolic heart failure (disorder)
15629541000119106	Congestive heart failure stage C due to ischemic cardiomyopathy (disorder)
15629591000119103	Congestive heart failure stage B due to ischemic cardiomyopathy (disorder)
15629641000119107	Systolic heart failure stage B due to ischemic cardiomyopathy (disorder)
15629741000119102	Systolic heart failure stage C due to ischemic cardiomyopathy (disorder)
15781000119107	Hypertensive heart AND chronic kidney disease with congestive heart failure (disorder)
15964701000119109	Acute cor pulmonale co-occurrent and due to saddle embolus of pulmonary artery (disorder)
194767001	Benign hypertensive heart disease with congestive cardiac failure (disorder)
194779001	Hypertensive heart and renal disease with (congestive) heart failure (disorder)
194781004	Hypertensive heart and renal disease with both (congestive) heart failure and renal failure (disorder)
195111005	Decompensated cardiac failure (disorder)
195112003	Compensated cardiac failure (disorder)
195114002	Acute left ventricular failure (disorder)
206586007	Congenital cardiac failure (disorder)
23341000119109	Congestive heart failure with right heart failure (disorder)
233924009	Heart failure as a complication of care (disorder)
25544003	Low output heart failure (disorder)
314206003	Refractory heart failure (disorder)
364006	Acute left-sided heart failure (disorder)
410431009	Cardiorespiratory failure (disorder)
417996009	Systolic heart failure (disorder)
418304008	Diastolic heart failure (disorder)
42343007	Congestive heart failure (disorder)
424404003	Decompensated chronic heart failure (disorder)
426263006	Congestive heart failure due to left ventricular systolic dysfunction (disorder)
426611007	Congestive heart failure due to valvular disease (disorder)
43736008	Rheumatic left ventricular failure (disorder)
44088000	Low cardiac output syndrome (disorder)
441481004	Chronic systolic heart failure (disorder)
441530006	Chronic diastolic heart failure (disorder)
44313006	Right heart failure secondary to left heart failure (disorder)
443253003	Acute on chronic systolic heart failure (disorder)
443254009	Acute systolic heart failure (disorder)
443343001	Acute diastolic heart failure (disorder)
443344007	Acute on chronic diastolic heart failure (disorder)
46113002	Hypertensive heart failure (disorder)
471880001	Heart failure due to end stage congenital heart disease (disorder)
48447003	Chronic heart failure (disorder)
5148006	Hypertensive heart disease with congestive heart failure (disorder)
5375005	Chronic left-sided congestive heart failure (disorder)
56675007	Acute heart failure (disorder)
67431000119105	Congestive heart failure stage D (disorder)
67441000119101	Congestive heart failure stage C (disorder)
698594003	Symptomatic congestive heart failure (disorder)
703272007	Heart failure with reduced ejection fraction (disorder)
703273002	Heart failure with reduced ejection fraction due to coronary artery disease (disorder)
703274008	Heart failure with reduced ejection fraction due to myocarditis (disorder)
703275009	Heart failure with reduced ejection fraction due to cardiomyopathy (disorder)
703276005	Heart failure with reduced ejection fraction due to heart valve disease (disorder)
717840005	Congestive heart failure stage B (disorder)
72481000119103	Congestive heart failure as early postoperative complication (disorder)
74960003	Acute left-sided congestive heart failure (disorder)
82523003	Congestive rheumatic heart failure (disorder)
83105008	Malignant hypertensive heart disease with congestive heart failure (disorder)
84114007	Heart failure (disorder)
85232009	Left heart failure (disorder)
871617000	Low output heart failure due to and following Fontan operation (disorder)
88805009	Chronic congestive heart failure (disorder)
90727007	Pleural effusion due to congestive heart failure (disorder)
92506005	Biventricular congestive heart failure (disorder)

 

ICD10:
Code	Description
I11.0	Hypertensive heart disease with heart failure
I13.0	Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
I13.2	Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease
I50.1	Left ventricular failure, unspecified
I50.20	Unspecified systolic (congestive) heart failure
I50.21	Acute systolic (congestive) heart failure
I50.22	Chronic systolic (congestive) heart failure
I50.23	Acute on chronic systolic (congestive) heart failure
I50.30	Unspecified diastolic (congestive) heart failure
I50.31	Acute diastolic (congestive) heart failure
I50.32	Chronic diastolic (congestive) heart failure
I50.33	Acute on chronic diastolic (congestive) heart failure
I50.40	Unspecified combined systolic (congestive) and diastolic (congestive) heart failure
I50.41	Acute combined systolic (congestive) and diastolic (congestive) heart failure
I50.42	Chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.43	Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.814	Right heart failure due to left heart failure
I50.82	Biventricular heart failure
I50.83	High output heart failure
I50.84	End stage heart failure
I50.89	Other heart failure
I50.9	Heart failure, unspecified

Hospice Services is captured by having an Inpatient Encounter with a Discharge for Hospice Care, or a Hospice Encounter, or Hospice Care Ambulatory Procedure Ordered or Performed, or a Hospice Diagnosis, or a Hospice Assessment with a result of Yes, during the measure period. In order to meet the requirements for the Hospice exclusion, at least one of the aforementioned must be documented in the chart and start before or during the measurement period:

Inpatient Encounter (SNOMED) during the measurement period that ends with Discharge for Hospice Care (SNOMED)
This is captured by adding a procedure with a valid SNOMED code using the Procedure widget in a note.

Encounter – Inpatient

SNOMED:
Code	Description
183452005	Emergency hospital admission (procedure)
32485007	Hospital admission (procedure)
8715000	Hospital admission, elective (procedure)

and

Discharge Code

SNOMED:
Code	Description
428361000124107	Discharge to home for hospice care (procedure)
428371000124100	Discharge to healthcare facility for hospice care (procedure)

 

Hospice Encounter (SNOMED or HCPCS) during or overlapping the measurement period

This is captured by adding a procedure with a valid SNOMED code using the Procedure widget in a note.

SNOMED:
Code	Description
183919006	Urgent admission to hospice (procedure)
183920000	Routine admission to hospice (procedure)
183921001	Admission to hospice for respite (procedure)
305336008	Admission to hospice (procedure)
305911006	Seen in hospice (finding)
385765002	Hospice care management (procedure)

 

HCPCS:
Code	Description
G9473	Services performed by chaplain in the hospice setting, each 15 minutes
G9474	Services performed by dietary counselor in the hospice setting, each 15 minutes
G9475	Services performed by other counselor in the hospice setting, each 15 minutes
G9476	Services performed by volunteer in the hospice setting, each 15 minutes
G9477	Services performed by care coordinator in the hospice setting, each 15 minutes
G9478	Services performed by other qualified therapist in the hospice setting, each 15 minutes
G9479	Services performed by qualified pharmacist in the hospice setting, each 15 minutes
Q5003	Hospice care provided in nursing long term care facility (ltc) or non-skilled nursing facility (nf)
Q5004	Hospice care provided in skilled nursing facility (snf)
Q5005	Hospice care provided in inpatient hospital
Q5006	Hospice care provided in inpatient hospice facility
Q5007	Hospice care provided in long term care facility
Q5008	Hospice care provided in inpatient psychiatric facility
Q5010	Hospice home care provided in a hospice facility
S9126	Hospice care, in the home, per diem
T2042	Hospice routine home care; per diem
T2043	Hospice continuous home care; per hour
T2044	Hospice inpatient respite care; per diem
T2045	Hospice general inpatient care; per diem
T2046	Hospice long term care, room and board only; per diem

 

Hospice Care Ambulatory Procedure (SNOMED, CPT, or HCPCS) during or overlapping the measurement period
This is captured by adding a procedure with a valid SNOMED, CPT, or HCPCS code using the Procedure widget in a note.

SNOMED:
Code	Description
385763009	Hospice care (regime/therapy)
385765002	Hospice care management (procedure)

 

CPT:
Code	Description
99377	Supervision of a hospice patient (patient not present) requiring complex and multidisciplinary care modalities involving regular development and/or revision of care plans by that individual, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in patient’s care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 15-29 minutes
99378	Supervision of a hospice patient (patient not present) requiring complex and multidisciplinary care modalities involving regular development and/or revision of care plans by that individual, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in patient’s care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 30 minutes or more

 

HCPCS:
Code	Description
G0182	Physician supervision of a patient under a medicare-approved hospice (patient not present) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of laboratory and other studies, communication (including telephone calls) with other health care professionals involved in the patient’s care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month, 30 minutes or more

 

Hospice Diagnosis (SNOMED) during or overlapping the measure period

This is captured by adding a diagnosis with a valid SNOMED code using the Diagnosis widget in a note.

SNOMED:
Code	Description
170935008	Full care by hospice (finding)
170936009	Shared care – hospice and general practitioner (finding)
305911006	Seen in hospice (finding)

 

Hospice Assessment overlapping the measure period

To qualify for the Hospice Assessment denominator exclusion, the patient must have a Hospice Assessment with a LOINC code of 45755-6 with a result finding of Yes, with a SNOMED code 373066001, that overlaps the measurement period.

This can be achieved by configuring a checklist with a Hospice Care checklist item, and then selecting that checklist item for applicable patients.

First, create or modify a procedure/result condition via Edit > System Tables > All Conditions.

In the Conditions Properties dialog, be sure to select the Procedure option and attach the 45755-6 code in the corresponding LOINC Code field.

Check the Result option, the 45755-6 code should also appear in the corresponding LOINC Code field.

 

Next, in the Template Editor, access the template you want to create or modify a checklist to include the Hospice Care item.

In the checklist, right click and select Insert finding…

In the Finding dialog, configure an applicable Heading; then and create Normal finding, for example Receiving Hospice Care; and then click Tag and attach the procedure/result configured above.

Click the SNOMED button and then attach the 373066001 SNOMED code to the tagged item.

After the checklist has been configured with the Hospice Care, and configured for the note template, whenever a patient is receiving hospice care, simply select this option in the checklist for the patient.