Diagnosis ICD – 9 Codes
 V 76.11, V76.12

Procedure ICD-9
87.36, 87.37

CPT Codes

76083, 76090-76092, 77055-77057

Exclusions Bilateral and Unilateral Mastectomy
Bilateral Mastectomy - CPT codes 19180, (19200, 19220, 19240, 19303-19307 with modifier .50 or modifier code 09950; ICD-9 Procedure codes 85.42, 85.44, 85.46 and 85.48)
Unilateral Mastectomy (members must have 2 separate occurrences on 2 different dates of service)
CPT codes (19180, 19200, 19220, 19240, 19303-19307;
ICD-9 Procedure codes 85.41, 85.43, 85.45, 85.47)

Women who are sexually active:

Diagnosis ICD – 9 Codes
 042, 054.10, 054.11, 054.12, 054.19, 078.1, 078.88, 079.4, 079.51-079.53, 079.88, 079.98, 091-097, 098.0, 098.10, 098.11, 098.15-098.19, 098.2, 098.30, 098.31, 098.35-098.8, 099, 131, 614-616, 622.3, 623.4, 626.7, 628, 630-677, 795.0, 996.32, V01.6, V02.7, V02.8, V08, V15.7, V22-V28, V45.5, V61.5-V61.7, V69.2, V72.3, V72.4, V73.88, V73.98, V74.5, V76.2V 76.11, V76.12

Procedure ICD-9 Codes
69.01, 69.02, 69.51, 69.52, 69.7, 72-75, 97.24, 97.71, 97.73, 87.36, 87.37

CPT Codes
11975-11977, 57022, 57170, 58300, 58301, 58600, 58605, 58611, 58615, 58970, 58974, 58976, 59000, 59001, 59012, 59015, 59020, 59025, 59030, 59050, 59051, 59070, 59072, 59074, 59076, 59100, 59120, 59121, 59130, 59135, 59136, 59140, 59150, 59151, 59160, 59200, 59300, 59320, 59325, 59350, 59400, 59409, 59410, 59412, 59414, 59425, 59426, 59430, 59510, 59514, 59515, 59525, 59610, 59612, 59614, 59618, 59620, 59622, 59812, 59820, 59821, 59830, 59840, 59841, 59850-59852, 59855-59857, 59866, 59870, 59871, 59897, 59898, 59899, 76801, 76805, 76811, 76813, 76815-76821, 76825-76828, 76941, 76945-76946, 80055, 81025, 82105, 82106, 82143, 82731, 83632, 83661-83664, 84163, 84702-84703, 86592-86593, 86631-86632, 87110, 87164, 87166, 87270, 87320, 87490-87492, 87590-87592, 87620-87622, 87660, 87800, 87801, 87808, 87810, 87850, 88141-88143, 88147, 88148, 88150, 88152-88155, 88164-88167, 88174-88175, 88235, 88267,

Chlamydia Test CPT Codes

76813, 87110, 87270, 87270, 87320,87490,87491,87492, 87660, 87810, 87808

Exclusion - Members who had a pregnancy test during the measurement year, followed within seven days by either a prescription for Accutane or an x-ray.  This exclusion does not apply to members who qualify based on services other than pregnancy test alone.

Pregnancy Test CPT codes 81025, 84702, 84703, WITH
Diagnostic Radiology CPT codes 70010-76499, Prescription for Accutane

Diagnosis ICD – 9 Codes
V72.32,V76.2

Procedure ICD-9 Codes
91.46

 CPT Codes

88141-88143, 88147, 88148, 88150, 88152-88155, 88164-88167, 88174-88175

Exclusions  - Hysterectomy with no residual cervix

Codes to Identify Exclusions

CPT 51925, 56308, 58150, 58152, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290-58294, 58550-58554, 58951, 58953, 58954, 58956, 59135

ICD-9 Diagnosis 618.5, V67.01, V76.47

ICD-9 Procedure 68.4-68.8

Note:

• Documentation of a “hysterectomy” does not meet the exclusion criteria. You must note hysterectomy with no residual cervix.
• Count any cervical cancer screening method that includes collection and microscopic analysis of cervical cells. Lab results that state the sample was inadequate or that no cervical cells were collected is not considered appropriate screening.
• Biopsies are not counted as they are considered diagnostic and therapeutic and not a screening tool.

Diagnosis ICD – 9 Codes
410.01, 410.11, 410.21, 410.31, 410.41, 410.51, 410.61, 410.71, 410.81, 410.91

Beta – Blocker Medications
(Circle the medication(s)
patient is receiving)

1. Noncardioselective Beta-blockers( carteolol, carvedilol, labetalol, nadolol,penbutolol, pindolol, prpranolol, timolol, sotalol)
2. Cardioselective Beta-blockers ( acebutolol, atenolol, betaxolol, bisoprolol, metoprolol)
3. Antihypertensive combinations
   atenolol- chlorthalidone,
   bendroflumethiazide-nadolol, bisoprolol-hydrochlorothiazide, hydro-
   chlorothiazide-propranolol, and hydrochlorothiazide - timolol

ICD-9 Code Exclusions – Contraindications or previous adverse reaction to beta-blocker therapy

Diabetes Diagnosis ICD – 9 Codes
250, 357.2, 362.0, 366.41, 648.0

CPT Office Visit Codes
92002-92014, 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341-99345, 99347-99350, 99384-99387, 99394-99397, 99401-99404, 99411, 99412, 99420, 99429, 99455, 99456, 99499

Exclusions:

• Exclude members with a diagnosis of polycystic ovaries (ICD-9 Diagnosis Code is 256.4) who do not have face-to-face encounters with a diagnosis of diabetes during or year prior to measurement year.
• Exclude members with gestational (ICD-9 Diagnosis code is 648.8) or steroid – induced diabetes (ICD9 Diagnosis codes are 251.8, 962.0) who do not have face-to-face encounters with a diagnosis of diabetes during or year prior to measurement year.

Measure

Description

Defined as one test performed during
measurement year as identified by claim encounter or laboratory data.

CPT - 83036, 83037

An eye screening for diabetic retinal disease includes diabetics who have had one of the following: A retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) or a negative retinal exam by an eye careprofessional in the year prior to the measurement year.

ICD-9 Diagnosis – V72.0
CPT - 67028, 67030, 67031, 67036, 67038-67040, 67101, 67105, 67107, 67108, 67110, 67112, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92225, 92226, 92230, 92235, 92240, 92250, 92260, 99203-99205, 99213-99215, 99242-99245

CPT –80061,83700,83704,83715,83716,83721

CPT –
81000-81003,81005

Group A Streptococcus Tests

87070, 87071, 87081, 87430, 87650-87652, 87880