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)

Ophthalmological Services

SNOMED:
Code	Description
359960003	Ophthalmologic examination and evaluation under general anesthesia, limited (procedure)
36228007	Ophthalmic examination and evaluation (procedure)
66902005	Ophthalmic examination and evaluation, follow-up (procedure)
78831002	Comprehensive eye examination (procedure)

 

CPT:
Code	Description
92002	Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient
92004	Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits
92012	Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient
92014	Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits

Preventive Care Services, 18 years old and Up

CPT:
Code	Description
99385	Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 18-39 years
99386	Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 40-64 years
99387	Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 65 years and older
99395	Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18-39 years
99396	Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years
99397	Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and older

Discharge Services Nursing Facility

CPT:
Code	Description
99315	Nursing facility discharge management; 30 minutes or less total time on the date of the encounter
99316	Nursing facility discharge management; more than 30 minutes total time on the date of the encounter

Nursing Facility Visit

SNOMED:
Code	Description
18170008	Subsequent nursing facility visit (procedure)
207195004	History and physical examination with evaluation and management of nursing facility patient (procedure)

 

CPT:
Code	Description
99304	Initial nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.
99305	Initial nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 35 minutes must be met or exceeded.
99306	Initial nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.
99307	Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 10 minutes must be met or exceeded.
99308	Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.
99309	Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.
99310	Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.
99315	Nursing facility discharge management; 30 minutes or less total time on the date of the encounter
99316	Nursing facility discharge management; more than 30 minutes total time on the date of the encounter
99318	Evaluation and management of a patient involving an annual nursing facility assessment, which requires these 3 key components: A detailed interval history; A comprehensive examination; and Medical decision making that is of low to moderate complexity. 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 patient is stable, recovering, or improving. Typically, 30 minutes are spent at the bedside and on the patient’s facility floor or unit.

Care Services in Long Term Residential Facility

SNOMED:
Code	Description
209099002	History and physical examination with management of domiciliary or rest home patient (procedure)
210098006	Domiciliary or rest home patient evaluation and management (procedure)

 

CPT:
Code	Description
99324	Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; and 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 of low severity. Typically, 20 minutes are spent with the patient and/or family or caregiver.
99325	Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. 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 of moderate severity. Typically, 30 minutes are spent with the patient and/or family or caregiver.
99326	Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. 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 of moderate to high severity. Typically, 45 minutes are spent with the patient and/or family or caregiver.
99327	Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. 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 of high severity. Typically, 60 minutes are spent with the patient and/or family or caregiver.
99328	Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. 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 patient is unstable or has developed a significant new problem requiring immediate physician attention. Typically, 75 minutes are spent with the patient and/or family or caregiver.
99334	Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused interval 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, 15 minutes are spent with the patient and/or family or caregiver.
99335	Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. 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 of low to moderate severity. Typically, 25 minutes are spent with the patient and/or family or caregiver.
99336	Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. 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 of moderate to high severity. Typically, 40 minutes are spent with the patient and/or family or caregiver.
99337	Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of moderate to high complexity. 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 of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 60 minutes are spent with the patient and/or family or caregiver.

Annual Wellness Visit

HCPCS:
Code	Description
G0438	Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit
G0439	Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit

 

SNOMED:
Code	Description
444971000124105	Annual wellness visit (procedure)
456201000124103	Medicare annual wellness visit (procedure)

Home Healthcare Services

CPT:
Code	Description
99341	Home or residence 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 total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.
99342	Home or residence 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 total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.
99343	Home visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. 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 of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family.
99344	Home or residence 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 total time on the date of the encounter for code selection, 60 minutes must be met or exceeded.
99345	Home or residence 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 total time on the date of the encounter for code selection, 75 minutes must be met or exceeded.
99347	Home or residence 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 total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.
99348	Home or residence 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 total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.
99349	Home or residence 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 total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.
99350	Home or residence 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 total time on the date of the encounter for code selection, 60 minutes must be met or exceeded.

 

SNOMED:
Code	Description
225929007	Joint home visit (procedure)
315205008	Bank holiday home visit (procedure)
439708006	Home visit (procedure)
698704008	Home visit for rheumatology service (procedure)
704126008	Home visit for anticoagulant drug monitoring (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

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.

Palliative Care is captured by having a Palliative Diagnosis, or a Palliative Encounter, or a Palliative Intervention, or a Palliative Care Assessment, during or overlapping the measure period. In order to meet the requirements for the Palliative Care exclusion, at least one of the aforementioned must be documented in the chart and start before or during the measurement period:

Palliative Diagnosis (ICD10 or SNOMED) overlapping the measure period

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

SNOMED:
Code	Description
305686008	Seen by palliative care physician (finding)
305824005	Seen by palliative care medicine service (finding)
441874000	Seen by palliative care service (finding)

 

ICD10:
Code	Description
Z51.5	Encounter for palliative care

 

Palliative Encounter (SNOMED or HCPCS) overlapping the measure period

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

SNOMED:
Code	Description
305284002	Admission by palliative care physician (procedure)
305381007	Admission to palliative care department (procedure)
4901000124101	Palliative care education (procedure)
713281006	Consultation for palliative care (procedure)

 

HCPCS:
Code	Description
G9054	Oncology; primary focus of visit; supervising, coordinating or managing care of patient with terminal cancer or for whom other medical illness prevents further cancer treatment; includes symptom management, end-of-life care planning, management of palliative therapies (for use in a medicare-approved demonstration project)
M1017	Patient admitted to palliative care services

 

Palliative Intervention (SNOMED) overlapping the measure period

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

SNOMED:
Code	Description
103735009	Palliative care (regime/therapy)
105402000	Visit of patient by chaplain during palliative care (regime/therapy)
1841000124106	Palliative care medication review (procedure)
395669003	Specialist palliative care treatment (regime/therapy)
395670002	Specialist palliative care treatment – inpatient (regime/therapy)
395694002	Specialist palliative care treatment – daycare (regime/therapy)
395695001	Specialist palliative care treatment – outpatient (regime/therapy)
433181000124107	Documentation of palliative care medication action plan (procedure)
443761007	Anticipatory palliative care (regime/therapy)

 

Palliative Care Assessment overlapping the measure period

To qualify for the Palliative Assessment denominator exclusion, the patient must have a Palliative Assessment with a LOINC code of 71007-9 that overlaps the measurement period.

This can be achieved by configuring a checklist with a Palliative 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 Palliative Care; and then click Tag and attach the procedure/result configured above.

 

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

 

SNOMED:
Code	Description
10875004	Severe mixed bipolar I disorder with psychotic features, mood-incongruent (disorder)
10981006	Severe mixed bipolar I disorder with psychotic features (disorder)
111485001	Mixed bipolar I disorder in full remission (disorder)
1196001	Chronic bipolar II disorder, most recent episode major depressive (disorder)
12969000	Severe bipolar II disorder, most recent episode major depressive, in full remission (disorder)
133091000119105	Rapid cycling bipolar I disorder (disorder)
13313007	Mild bipolar disorder (disorder)
13581000	Severe bipolar I disorder, single manic episode with psychotic features, mood-congruent (disorder)
13746004	Bipolar disorder (disorder)
14495005	Severe bipolar I disorder, single manic episode without psychotic features (disorder)
1499003	Bipolar I disorder, single manic episode with postpartum onset (disorder)
162004	Severe manic bipolar I disorder without psychotic features (disorder)
16238741000119105	Bipolar disorder caused by drug (disorder)
16295005	Bipolar II disorder, most recent episode major depressive (disorder)
16506000	Mixed bipolar I disorder (disorder)
17782008	Bipolar I disorder, most recent episode manic with catatonic features (disorder)
191618007	Bipolar affective disorder, current episode manic (disorder)
191620005	Bipolar affective disorder, currently manic, mild (disorder)
191621009	Bipolar affective disorder, currently manic, moderate (disorder)
191623007	Bipolar affective disorder, currently manic, severe, with psychosis (disorder)
191625000	Bipolar affective disorder, currently manic, in full remission (disorder)
191627008	Bipolar affective disorder, current episode depression (disorder)
191629006	Bipolar affective disorder, currently depressed, mild (disorder)
191630001	Bipolar affective disorder, currently depressed, moderate (disorder)
191634005	Bipolar affective disorder, currently depressed, in full remission (disorder)
191636007	Mixed bipolar affective disorder (disorder)
191638008	Mixed bipolar affective disorder, mild (disorder)
191639000	Mixed bipolar affective disorder, moderate (disorder)
191641004	Mixed bipolar affective disorder, severe, with psychosis (disorder)
191643001	Mixed bipolar affective disorder, in full remission (disorder)
192362008	Bipolar affective disorder, current episode mixed (disorder)
19300006	Severe bipolar II disorder, most recent episode major depressive with psychotic features, mood-congruent (disorder)
20960007	Severe bipolar II disorder, most recent episode major depressive with psychotic features, mood-incongruent (disorder)
21900002	Bipolar I disorder, most recent episode depressed with catatonic features (disorder)
22121000	Depressed bipolar I disorder in full remission (disorder)
22407005	Bipolar II disorder, most recent episode major depressive with catatonic features (disorder)
231444002	Organic bipolar disorder (disorder)
23741000119105	Severe manic bipolar I disorder (disorder)
261000119107	Severe depressed bipolar I disorder (disorder)
26203008	Severe depressed bipolar I disorder with psychotic features, mood-incongruent (disorder)
26530004	Severe bipolar disorder with psychotic features, mood-incongruent (disorder)
271000119101	Severe mixed bipolar I disorder (disorder)
28663008	Severe manic bipolar I disorder with psychotic features (disorder)
28884001	Moderate bipolar I disorder, single manic episode (disorder)
29929003	Bipolar I disorder, most recent episode depressed with atypical features (disorder)
30520009	Severe bipolar II disorder, most recent episode major depressive with psychotic features (disorder)
30687003	Bipolar II disorder, most recent episode major depressive with postpartum onset (disorder)
30935000	Manic bipolar I disorder in full remission (disorder)
31446002	Bipolar I disorder, most recent episode hypomanic (disorder)
33380008	Severe manic bipolar I disorder with psychotic features, mood-incongruent (disorder)
34315001	Bipolar II disorder, most recent episode major depressive with melancholic features (disorder)
3530005	Bipolar I disorder, single manic episode, in full remission (disorder)
35481005	Mixed bipolar I disorder in remission (disorder)
35722002	Severe bipolar II disorder, most recent episode major depressive, in remission (disorder)
35846004	Moderate bipolar II disorder, most recent episode major depressive (disorder)
36583000	Mixed bipolar I disorder in partial remission (disorder)
371596008	Bipolar I disorder (disorder)
371599001	Severe bipolar I disorder (disorder)
371600003	Severe bipolar disorder (disorder)
371604007	Severe bipolar II disorder (disorder)
40926005	Moderate mixed bipolar I disorder (disorder)
41552001	Mild bipolar I disorder, single manic episode (disorder)
41832009	Severe bipolar I disorder, single manic episode with psychotic features (disorder)
41836007	Bipolar disorder in full remission (disorder)
43568002	Bipolar II disorder, most recent episode major depressive with atypical features (disorder)
43769008	Mild mixed bipolar I disorder (disorder)
4441000	Severe bipolar disorder with psychotic features (disorder)
45479006	Manic bipolar I disorder in remission (disorder)
46229002	Severe mixed bipolar I disorder without psychotic features (disorder)
48937005	Bipolar II disorder, most recent episode hypomanic (disorder)
49468007	Depressed bipolar I disorder (disorder)
49512000	Depressed bipolar I disorder in partial remission (disorder)
51637008	Chronic bipolar I disorder, most recent episode depressed (disorder)
53049002	Severe bipolar disorder without psychotic features (disorder)
53607008	Depressed bipolar I disorder in remission (disorder)
54761006	Severe depressed bipolar I disorder with psychotic features, mood-congruent (disorder)
55516002	Bipolar I disorder, most recent episode manic with postpartum onset (disorder)
5703000	Bipolar disorder in partial remission (disorder)
59617007	Severe depressed bipolar I disorder with psychotic features (disorder)
61403008	Severe depressed bipolar I disorder without psychotic features (disorder)
63249007	Manic bipolar I disorder in partial remission (disorder)
64731001	Severe mixed bipolar I disorder with psychotic features, mood-congruent (disorder)
65042007	Bipolar I disorder, most recent episode mixed with postpartum onset (disorder)
66631006	Moderate depressed bipolar I disorder (disorder)
67002003	Severe bipolar II disorder, most recent episode major depressive, in partial remission (disorder)
68569003	Manic bipolar I disorder (disorder)
70546001	Severe bipolar disorder with psychotic features, mood-congruent (disorder)
71294008	Mild bipolar II disorder, most recent episode major depressive (disorder)
71984005	Mild manic bipolar I disorder (disorder)
723903001	Bipolar type I disorder currently in full remission (disorder)
723905008	Bipolar type II disorder currently in full remission (disorder)
73471000	Bipolar I disorder, most recent episode mixed with catatonic features (disorder)
74686005	Mild depressed bipolar I disorder (disorder)
75360000	Bipolar I disorder, single manic episode, in remission (disorder)
75752004	Bipolar I disorder, most recent episode depressed with melancholic features (disorder)
765176007	Psychosis and severe depression co-occurrent and due to bipolar affective disorder (disorder)
767631007	Bipolar disorder, most recent episode depression (disorder)
767632000	Bipolar disorder, most recent episode manic (disorder)
767633005	Bipolar affective disorder, most recent episode mixed (disorder)
767635003	Bipolar I disorder, most recent episode manic (disorder)
767636002	Bipolar I disorder, most recent episode depression (disorder)
78269000	Bipolar I disorder, single manic episode, in partial remission (disorder)
78640000	Severe manic bipolar I disorder with psychotic features, mood-congruent (disorder)
789061003	Rapid cycling bipolar II disorder (disorder)
79584002	Moderate bipolar disorder (disorder)
81319007	Severe bipolar II disorder, most recent episode major depressive without psychotic features (disorder)
82998009	Moderate manic bipolar I disorder (disorder)
83225003	Bipolar II disorder (disorder)
85248005	Bipolar disorder in remission (disorder)
86058007	Severe bipolar I disorder, single manic episode with psychotic features, mood-incongruent (disorder)
87203005	Bipolar I disorder, most recent episode depressed with postpartum onset (disorder)
87950005	Bipolar I disorder, single manic episode with catatonic features (disorder)
9340000	Bipolar I disorder, single manic episode (disorder)

 

ICD9:
Code	Description
296.00	Bipolar I disorder, single manic episode, unspecified
296.01	Bipolar I disorder, single manic episode, mild
296.02	Bipolar I disorder, single manic episode, moderate
296.03	Bipolar I disorder, single manic episode, severe, without mention of psychotic behavior
296.04	Bipolar I disorder, single manic episode, severe, specified as with psychotic behavior
296.05	Bipolar I disorder, single manic episode, in partial or unspecified remission
296.06	Bipolar I disorder, single manic episode, in full remission
296.10	Manic affective disorder, recurrent episode, unspecified
296.11	Manic affective disorder, recurrent episode, mild
296.12	Manic affective disorder, recurrent episode, moderate
296.13	Manic affective disorder, recurrent episode, severe, without mention of psychotic behavior
296.14	Manic affective disorder, recurrent episode, severe, specified as with psychotic behavior
296.15	Manic affective disorder, recurrent episode, in partial or unspecified remission
296.16	Manic affective disorder, recurrent episode, in full remission
296.40	Bipolar I disorder, most recent episode (or current) manic, unspecified
296.41	Bipolar I disorder, most recent episode (or current) manic, mild
296.42	Bipolar I disorder, most recent episode (or current) manic, moderate
296.43	Bipolar I disorder, most recent episode (or current) manic, severe, without mention of psychotic behavior
296.44	Bipolar I disorder, most recent episode (or current) manic, severe, specified as with psychotic behavior
296.45	Bipolar I disorder, most recent episode (or current) manic, in partial or unspecified remission
296.46	Bipolar I disorder, most recent episode (or current) manic, in full remission
296.50	Bipolar I disorder, most recent episode (or current) depressed, unspecified
296.51	Bipolar I disorder, most recent episode (or current) depressed, mild
296.52	Bipolar I disorder, most recent episode (or current) depressed, moderate
296.53	Bipolar I disorder, most recent episode (or current) depressed, severe, without mention of psychotic behavior
296.54	Bipolar I disorder, most recent episode (or current) depressed, severe, specified as with psychotic behavior
296.55	Bipolar I disorder, most recent episode (or current) depressed, in partial or unspecified remission
296.56	Bipolar I disorder, most recent episode (or current) depressed, in full remission
296.60	Bipolar I disorder, most recent episode (or current) mixed, unspecified
296.61	Bipolar I disorder, most recent episode (or current) mixed, mild
296.62	Bipolar I disorder, most recent episode (or current) mixed, moderate
296.63	Bipolar I disorder, most recent episode (or current) mixed, severe, without mention of psychotic behavior
296.64	Bipolar I disorder, most recent episode (or current) mixed, severe, specified as with psychotic behavior
296.65	Bipolar I disorder, most recent episode (or current) mixed, in partial or unspecified remission
296.66	Bipolar I disorder, most recent episode (or current) mixed, in full remission
296.7	Bipolar I disorder, most recent episode (or current) unspecified
296.80	Bipolar disorder, unspecified
296.81	Atypical manic disorder
296.82	Atypical depressive disorder
296.89	Other bipolar disorders

 

ICD10:
Code	Description
F30.10	Manic episode without psychotic symptoms, unspecified
F30.11	Manic episode without psychotic symptoms, mild
F30.12	Manic episode without psychotic symptoms, moderate
F30.13	Manic episode, severe, without psychotic symptoms
F30.2	Manic episode, severe with psychotic symptoms
F30.3	Manic episode in partial remission
F30.4	Manic episode in full remission
F30.8	Other manic episodes
F30.9	Manic episode, unspecified
F31.0	Bipolar disorder, current episode hypomanic
F31.10	Bipolar disorder, current episode manic without psychotic features, unspecified
F31.11	Bipolar disorder, current episode manic without psychotic features, mild
F31.12	Bipolar disorder, current episode manic without psychotic features, moderate
F31.13	Bipolar disorder, current episode manic without psychotic features, severe
F31.2	Bipolar disorder, current episode manic severe with psychotic features
F31.30	Bipolar disorder, current episode depressed, mild or moderate severity, unspecified
F31.31	Bipolar disorder, current episode depressed, mild
F31.32	Bipolar disorder, current episode depressed, moderate
F31.4	Bipolar disorder, current episode depressed, severe, without psychotic features
F31.5	Bipolar disorder, current episode depressed, severe, with psychotic features
F31.60	Bipolar disorder, current episode mixed, unspecified
F31.61	Bipolar disorder, current episode mixed, mild
F31.62	Bipolar disorder, current episode mixed, moderate
F31.63	Bipolar disorder, current episode mixed, severe, without psychotic features
F31.64	Bipolar disorder, current episode mixed, severe, with psychotic features
F31.70	Bipolar disorder, currently in remission, most recent episode unspecified
F31.71	Bipolar disorder, in partial remission, most recent episode hypomanic
F31.72	Bipolar disorder, in full remission, most recent episode hypomanic
F31.73	Bipolar disorder, in partial remission, most recent episode manic
F31.74	Bipolar disorder, in full remission, most recent episode manic
F31.75	Bipolar disorder, in partial remission, most recent episode depressed
F31.76	Bipolar disorder, in full remission, most recent episode depressed
F31.77	Bipolar disorder, in partial remission, most recent episode mixed
F31.78	Bipolar disorder, in full remission, most recent episode mixed
F31.81	Bipolar II disorder
F31.89	Other bipolar disorder
F31.9	Bipolar disorder, unspecified