HEDIS Code Quick Reference Guide—Women’s Health Services

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HEDIS Code Quick Reference Guide—Women’s Health Services

Women’s Health

Breast Cancer Screening (ages 40-69) [Commercial, Medicaid, Medicare]

Codes to identify Breast Cancer Screening

CPT HCPCS ICD-9-CM Procedure UB Revenue

77055-77057 G0202, G0204, G0206 87.36, 87.37 0401, 0403

EXCLUSIONS: CPT ICD-9-CM Procedure

Bilateral mastectomyUse Unilateral code WITH bilateral modifier .50 or 09950 to

indicate the procedure was bilateral and performed during the same operative session.

85.42, 85.44, 85.46, 85.48

Unilateral mastectomy 19180, 19200, 19220, 19240, 19303-19307 (Modifiers: Right=RT, Left=LT) 85.41, 85.43, 85.45, 85.47

Cervical Cancer Screening (ages 21-64) [Commercial, Medicaid]

Codes to identify Cervical Cancer Screening

CPT HCPCS ICD-9-CM Procedure UB Revenue LOINC

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

G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091 91.46 0923

10524-7, 18500-9, 19762-4, 19764-0, 19765-7, 19766-5, 19774-9, 33717-0, 47527-7,

47528-5

EXCLUSIONS: CPT ICD-9-CM Diagnosis ICD-9-CM Procedure

Hysterectomy51925, 56308, 57540, 57545, 57550, 57555, 57556, 58150, 58152, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290-58294, 58548, 58550-

58554, 58570-58573, 58951, 58953, 58954, 58956, 59135

618.5, V67.01, V76.47, V88.01, V88.03, 752.43 68.4-68.8

Chlamydia Screening in Women (ages 16-24) [Commercial, Medicaid]

Codes to identify Chlamydia Screening

CPT LOINC

87110, 87270, 87320, 87490-87492, 87810

557-9, 560-3, 4993-2, 6349-5, 6354-5, 6355-2, 6356-0, 6357-8, 14463-4, 14464-2, 14467-5, 14470-9, 14471-7, 14474-1, 14509-4, 14510-2, 14513-6, 16600-9, 16601-7, 21189-6, 21190-4, 21191-2, 21192-0, 21613-5, 23838-6, 31771-9, 31772-7, 31775-0, 31777-6, 36902-5, 36903-3, 42931-6, 43304-5, 43404-3, 43406-8, 44806-8, 44807-6, 45067-6, 45068-4, 45069-2, 45070-0, 45074-2, 45076-7, 45078-3,

45080-9, 45084-1, 45091-6, 45095-7, 45098-1, 45100-5, 47211-8, 47212-6, 49096-1, 50387-0, 53925-4, 53926-2

EXCLUSIONS: CPT UB Revenue LOINC

Pregnancy test 81025, 84702, 84703 9252106-3, 2107-1, 2110-5, 2111-3, 2112-1, 2113-9, 2114-7, 2115-4, 2118-8, 2119-6, 19080-1, 19180-9, 20415-6, 20994-0, 21198-7, 25372-4, 25373-2,

34670-0, 45194-8, 55869-2, 55870-0, 56497-1

WITH

Diagnostic radiology 70010-76499 032x

Retinoid Isotretinoin prescription

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Pregnancy Care

Postpartum Care [Commercial, Medicaid]

Codes to identify Postpartum Visits

CPT (Preferred Codes) CPT Category II HCPCS ICD-9-CM

DiagnosisICD-9-CM Procedure UB Revenue LOINC

57170, 58300, 59400,* 59410,* 59430, 59510,* 59515,* 59610,* 59614,* 59618,*

59622,* 88141-88143, 88147, 88148, 88150, 88152-88155, 88164-88167, 88174, 88175, 99501 (*Generally, these codes are used on the date of delivery. Code may be used only if

the claim form indicates when postpartum care was rendered.)

0503F

G0101, G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000,

P3001, Q0091

V24.1, V24.2, V25.1, V72.3,

V76.289.26, 91.46 0923

10524-7, 18500-9, 19762-4, 19764-0, 19765-7, 19766-5, 19774-9, 33717-0, 47527-7,

47528-5

Prenatal Care [Commercial, Medicaid]

Basic Codes to identify Prenatal Care Visits

CPT ICD-9-CM Diagnosis

59400,* 59425,* 59426,* 59510,* 59610,* 59618* (* Generally, these codes are used on the date of delivery. Code is useful only if the claim form indicates when

prenatal care was initiated.)WITH

640.x3, 641.x3, 642.x3, 643.x3, 644.x3, 645.x3, 646.x3, 647.x3, 648.x3, 649.x3, 651.x3, 652.x3, 653.x3, 654.x3, 655.x3, 656.x3, 657.x3, 658.x3, 659.x3, 678.x3,

679.x3, V22, V23, V28

CPT Category II

0500F, 0501F, 0502F

Well Care

Adults’ Access to Preventive/Ambulatory Health Services

(ages 20-65) [Commercial, Medicaid, Medicare]

Codes to identify Ambulatory or Preventive Care Visit

Description CPT HCPCS ICD-9-CM Diagnosis UB Revenue

Office or other outpatient services 99201-99205, 99211-99215, 99241-99245

051x, 0520-0523, 0526-0529, 0982,

0983

Home services 99341-99345, 99347-99350

Nursing facility care 99304-99310, 99315, 99316, 99318

Domiciliary, rest home or custodial care services 99324-99328, 99334-99337

Preventive medicine 99385-99387, 99395-99397, 99401-99404, 99411, 99412, 99420, 99429

G0402, G0438, G0439

Ophthalmology and optometry 92002, 92004, 92012, 92014 S0620, S0621

General medical examination V70.0, V70.3, V70.5, V70.6, V70.8, V70.9

Adolescent Well-Care Visits (ages 12-21) [Commercial, Medicaid]

Codes to identify Adolescent Well-Care Visits

CPT HCPCS ICD-9-CM Diagnosis

99383-99385, 99393-99395 G0438, G0439 V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9

Source: HEDIS 2013 Technical SpecificationsAllowable codes may vary by state. Reimbursement for these services will be per the terms of your agreement.

HEDIS Code Quick Reference Guide—Women’s Health Services

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