| G8 |
Monitored anesthesia care |
Monitored anesthesia care (mac) for deep complex, complicated, or markedly invasive surgical procedure |
| G8126 |
Pt treat w/antidepress12wks |
Patient with a diagnosis of major depression documented as being treated with antidepressant medication during the entire 84 day (12 week) acute treatment phase |
| G8127 |
Pt not treat w/antidepres12w |
Patient with a diagnosis of major depression not documented as being treated with antidepressant medication during the entire 84 day (12 week) acute treatment phase |
| G8128 |
Pt inelig for antidepres med |
Clinician documented that patient was not an eligible candidate for antidepressant medication during the entire 12 week acute treatment phase measure |
| G8395 |
Lvef>=40% doc normal or mild |
Left ventricular ejection fraction (lvef) >= 40% or documentation as normal or mildly depressed left ventricular systolic function |
| G8396 |
Lvef not performed |
Left ventricular ejection fraction (lvef) not performed or documented |
| G8397 |
Dil macula/fundus exam/w doc |
Dilated macular or fundus exam performed, including documentation of the presence or absence of macular edema and level of severity of retinopathy |
| G8398 |
Dil macular/fundus not perfo |
Dilated macular or fundus exam not performed |
| G8399 |
Pt w/dxa results document |
Patient with documented results of a central dual-energy x-ray absorptiometry (dxa) ever being performed |
| G8400 |
Pt w/dxa no results doc |
Patient with central dual-energy x-ray absorptiometry (dxa) results not documented, reason not given |
| G8401 |
Pt inelig osteo screen measu |
Clinician documented that patient was not an eligible candidate for screening |
| G8404 |
Low extemity neur exam docum |
Lower extremity neurological exam performed and documented |
| G8405 |
Low extemity neur not perfor |
Lower extremity neurological exam not performed |
| G8406 |
Pt inelig lower extrem neuro |
Clinician documented that patient was not an eligible candidate for lower extremity neurological exam measure |
| G8410 |
Eval on foot documented |
Footwear evaluation performed and documented |
| G8415 |
Eval on foot not performed |
Footwear evaluation was not performed |
| G8416 |
Pt inelig footwear evaluatio |
Clinician documented that patient was not an eligible candidate for footwear evaluation measure |
| G8417 |
Calc bmi abv up param f/u |
Bmi is documented above normal parameters and a follow-up plan is documented |
| G8418 |
Calc bmi blw low param f/u |
Bmi is documented below normal parameters and a follow-up plan is documented |
| G8419 |
Calc bmi out nrm param nof/u |
Bmi documented outside normal parameters, no follow-up plan documented, no reason given |
| G8420 |
Calc bmi norm parameters |
Bmi is documented within normal parameters and no follow-up plan is required |
| G8421 |
Bmi not calculated |
Bmi not documented and no reason is given |
| G8422 |
Pt inelig bmi calculation |
Bmi not documented, documentation the patient is not eligible for bmi calculation |
| G8427 |
Docrev cur meds by elig clin |
Eligible clinician attests to documenting in the medical record they obtained, updated, or reviewed the patient's current medications |
| G8428 |
Cur meds not document |
Current list of medications not documented as obtained, updated, or reviewed by the eligible clinician, reason not given |
| G8430 |
Doc med rsn no medrec |
Documentation of a medical reason(s) for not documenting, updating, or reviewing the patient's current medications list (e.g., patient is in an urgent or emergent medical situation) |
| G8431 |
Pos clin depres scrn f/u doc |
Screening for depression is documented as being positive and a follow-up plan is documented |
| G8432 |
Dep scr not doc, rng |
Depression screening not documented, reason not given |
| G8433 |
Scr for dep not cpt doc rsn |
Screening for depression not completed, documented patient or medical reason |
| G8442 |
Doc pain as nt perf, not elg |
Pain assessment not documented as being performed, documentation the patient is not eligible for a pain assessment using a standardized tool at the time of the encounter |
| G8450 |
Beta-bloc rx pt w/abn lvef |
Beta-blocker therapy prescribed |
| G8451 |
Pt w/abn lvef inelig b-bloc |
Beta-blocker therapy for lvef <=40% not prescribed for reasons documented by the clinician (e.g., low blood pressure, fluid overload, asthma, patients recently treated with an intravenous positive inotropic agent, allergy, intolerance, other medical reasons, patient declined, other patient reasons) |
| G8452 |
Pt w/abn lvef b-bloc no rx |
Beta-blocker therapy not prescribed |
| G8458 |
Pt inelig geno no antvir tx |
Clinician documented that patient is not an eligible candidate for genotype testing; patient not receiving antiviral treatment for hepatitis c during the measurement period (e.g. genotype test done prior to the reporting period, patient declines, patient not a candidate for antiviral treatment) |
| G8460 |
Pt inelig rna no antvir tx |
Clinician documented that patient is not an eligible candidate for quantitative rna testing at week 12; patient not receiving antiviral treatment for hepatitis c |
| G8461 |
Pt rec antivir treat hep c |
Patient receiving antiviral treatment for hepatitis c during the measurement period |
| G8464 |
Pt inelig; lo to no dter rsk |
Clinician documented that prostate cancer patient is not an eligible candidate for adjuvant hormonal therapy; low or intermediate risk of recurrence or risk of recurrence not determined |
| G8465 |
High risk recurrence pro ca |
High or very high risk of recurrence of prostate cancer |
| G8473 |
Ace/arb thxpy rx'd |
Angiotensin converting enzyme (ace) inhibitor or angiotensin receptor blocker (arb) therapy prescribed |
| G8474 |
Ace/arb not rx'd; doc reas |
Angiotensin converting enzyme (ace) inhibitor or angiotensin receptor blocker (arb) therapy not prescribed for reasons documented by the clinician (e.g., allergy, intolerance, pregnancy, renal failure due to ace inhibitor, diseases of the aortic or mitral valve, other medical reasons) or (e.g., patient declined, other patient reasons) |
| G8475 |
Ace/arb thxpy not rx'd |
Angiotensin converting enzyme (ace) inhibitor or angiotensin receptor blocker (arb) therapy not prescribed, reason not given |
| G8476 |
Bp sys <140 and dias <90 |
Most recent blood pressure has a systolic measurement of < 140 mmhg and a diastolic measurement of < 90 mmhg |
| G8477 |
Bp sys>=140 and/or dias >=90 |
Most recent blood pressure has a systolic measurement of >= 140 mmhg and/or a diastolic measurement of >= 90 mmhg |
| G8478 |
Bp not performed/doc |
Blood pressure measurement not performed or documented, reason not given |
| G8482 |
Flu immunize order/admin |
Influenza immunization administered or previously received |
| G8483 |
Flu imm no admin doc rea |
Influenza immunization was not administered for reasons documented by clinician (e.g., patient allergy or other medical reasons, patient declined or other patient reasons, vaccine not available or other system reasons) |
| G8484 |
Flu immunize no admin |
Influenza immunization was not administered, reason not given |
| G8485 |
Report, diabetes measures |
I intend to report the diabetes mellitus (dm) measures group |
| G8486 |
Report, prev care measures |
I intend to report the preventive care measures group |
| G8487 |
Report ckd measures |
I intend to report the chronic kidney disease (ckd) measures group |
| G8489 |
Cad measures grp |
I intend to report the coronary artery disease (cad) measures group |
| G8490 |
Ra measures grp |
I intend to report the rheumatoid arthritis (ra) measures group |
| G8491 |
Hiv/aids measures grp |
I intend to report the hiv/aids measures group |
| G8492 |
Periop care measures grp |
I intend to report the perioperative care measures group |
| G8493 |
Back pain measures grp |
I intend to report the back pain measures group |
| G8494 |
Dm meas qual act perform |
All quality actions for the applicable measures in the diabetes mellitus (dm) measures group have been performed for this patient |
| G8495 |
Ckd meas qual act perform |
All quality actions for the applicable measures in the chronic kidney disease (ckd) measures group have been performed for this patient |
| G8496 |
Prev care mg qual act perfrm |
All quality actions for the applicable measures in the preventive care measures group have been performed for this patient |
| G8497 |
Cabg meas qual act perform |
All quality actions for the applicable measures in the coronary artery bypass graft (cabg) measures group have been performed for this patient |
| G8498 |
Cad meas qual act perform |
All quality actions for the applicable measures in the coronary artery disease (cad) measures group have been performed for this patient |
| G8499 |
Ra meas qual act perform |
All quality actions for the applicable measures in the rheumatoid arthritis (ra) measures group have been performed for this patient |
| G8500 |
Hiv meas qual act perform |
All quality actions for the applicable measures in the hiv/aids measures group have been performed for this patient |
| G8501 |
Perio meas qual act perform |
All quality actions for the applicable measures in the perioperative care measures group have been performed for this patient |
| G8502 |
Back pain mg qual act perfrm |
All quality actions for the applicable measures in the back pain measures group have been performed for this patient |
| G8506 |
Pt rec ace/arb |
Patient receiving angiotensin converting enzyme (ace) inhibitor or angiotensin receptor blocker (arb) therapy |
| G8509 |
Pos pain assess no f/u doc |
Pain assessment documented as positive using a standardized tool, follow-up plan not documented, reason not given |
| G8510 |
Scr dep neg, no plan reqd |
Screening for depression is documented as negative, a follow-up plan is not required |
| G8511 |
Scr dep pos, no plan doc rng |
Screening for depression documented as positive, follow-up plan not documented, reason not given |
| G8530 |
Auto av fistula recd |
Autogenous av fistula received |
| G8531 |
Pt inelig; auto av fistula |
Clinician documented that patient was not an eligible candidate for autogenous av fistula |
| G8532 |
No auto av fistula; no reas |
Clinician documented that patient received vascular access other than autogenous av fistula, reason not given |
| G8535 |
Eld maltreatment not doc |
Elder maltreatment screen not documented; documentation that patient is not eligible for the elder maltreatment screen at the time of the encounter related to one of the following reasons: (1) patient refuses to participate in the screening and has reasonable decisional capacity for self-protection, or (2) patient is in an urgent or emergent situation where time is of the essence and to delay treatment to perform the screening would jeopardize the patient's health status |
| G8536 |
No doc elder mal scrn |
No documentation of an elder maltreatment screen, reason not given |
| G8539 |
Doc funct and care plan |
Functional outcome assessment documented as positive using a standardized tool and a care plan based on identified deficiencies is documented within two days of the functional outcome assessment |
| G8540 |
Foa not doc as being perf |
Functional outcome assessment not documented as being performed, documentation the patient is not eligible for a functional outcome assessment using a standardized tool at the time of the encounter |
| G8541 |
No doc cur funct assess |
Functional outcome assessment using a standardized tool not documented, reason not given |
| G8542 |
Doc funct no deficiencies |
Functional outcome assessment using a standardized tool is documented; no functional deficiencies identified, care plan not required |
| G8543 |
Cur funct asses; no care pln |
Documentation of a positive functional outcome assessment using a standardized tool; care plan not documented within two days of assessment, reason not given |
| G8544 |
Cabg measures grp |
I intend to report the coronary artery bypass graft (cabg) measures group |
| G8545 |
Hepc measures grp |
I intend to report the hepatitis c measures group |
| G8547 |
Ivd measures grp |
I intend to report the ischemic vascular disease (ivd) measures group |
| G8548 |
Hf measures grp |
I intend to report the heart failure (hf) measures group |
| G8549 |
Hepc mg qual act perform |
All quality actions for the applicable measures in the hepatitis c measures group have been performed for this patient |
| G8551 |
Hf mg qual act perform |
All quality actions for the applicable measures in the heart failure (hf) measures group have been performed for this patient |
| G8552 |
Ivd mg qual act perform |
All quality actions for the applicable measures in the ischemic vascular disease (ivd) measures group have been performed for this patient |
| G8559 |
Pt ref doc oto eval |
Patient referred to a physician (preferably a physician with training in disorders of the ear) for an otologic evaluation |
| G8560 |
Pt hx act drain prev 90 days |
Patient has a history of active drainage from the ear within the previous 90 days |
| G8561 |
Pt inelig for ref oto eval |
Patient is not eligible for the referral for otologic evaluation for patients with a history of active drainage measure |
| G8562 |
Pt no hx act drain 90 d |
Patient does not have a history of active drainage from the ear within the previous 90 days |
| G8563 |
Pt no ref oto reas no spec |
Patient not referred to a physician (preferably a physician with training in disorders of the ear) for an otologic evaluation, reason not given |
| G8564 |
Pt ref oto eval |
Patient was referred to a physician (preferably a physician with training in disorders of the ear) for an otologic evaluation, reason not specified) |
| G8565 |
Ver doc hear loss |
Verification and documentation of sudden or rapidly progressive hearing loss |
| G8566 |
Pt inelig ref oto eval |
Patient is not eligible for the referral for otologic evaluation for sudden or rapidly progressive hearing loss measure |
| G8567 |
Pt no doc hear loss |
Patient does not have verification and documentation of sudden or rapidly progressive hearing loss |
| G8568 |
Pt no ref otolo no spec |
Patient was not referred to a physician (preferably a physician with training in disorders of the ear) for an otologic evaluation, reason not given |
| G8569 |
Prol intubation req |
Prolonged postoperative intubation (> 24 hrs) required |
| G8570 |
No prol intub req |
Prolonged postoperative intubation (> 24 hrs) not required |
| G8571 |
Ster wd ifx 30 d postop |
Development of deep sternal wound infection/mediastinitis within 30 days postoperatively |
| G8572 |
No ster wd ifx |
No deep sternal wound infection/mediastinitis |
| G8573 |
Stk cabg |
Stroke following isolated cabg surgery |
| G8574 |
No strk cabg |
No stroke following isolated cabg surgery |
| G8575 |
Postop ren fail |
Developed postoperative renal failure or required dialysis |
| G8576 |
No postop ren fail |
No postoperative renal failure/dialysis not required |
| G8577 |
Reop req bld grft oth |
Re-exploration required due to mediastinal bleeding with or without tamponade, graft occlusion, valve dysfunction or other cardiac reason |
| G8578 |
No reop req bld grft oth |
Re-exploration not required due to mediastinal bleeding with or without tamponade, graft occlusion, valve dysfunction or other cardiac reason |
| G8579 |
Antplt med disch |
Antiplatelet medication at discharge |
| G8580 |
Antplt med contraind |
Antiplatelet medication contraindicated |
| G8581 |
No antplt med disch |
No antiplatelet medication at discharge |
| G8582 |
Bblock disch |
Beta-blocker at discharge |
| G8583 |
Bblock contraind |
Beta-blocker contraindicated |
| G8584 |
No bblock disch |
No beta-blocker at discharge |
| G8585 |
Antilipid treat disch |
Anti-lipid treatment at discharge |
| G8586 |
Antlip disch contra |
Anti-lipid treatment contraindicated |
| G8587 |
No antlipid treat disch |
No anti-lipid treatment at discharge |
| G8593 |
Lipid pn results |
Lipid profile results documented and reviewed (must include total cholesterol, hdl-c, triglycerides and calculated ldl-c) |
| G8594 |
No lipid prof perf |
Lipid profile not performed, reason not given |
| G8595 |
Ldl < 100 |
Most recent ldl-c < 100 mg/dl |
| G8597 |
Ldl >= 100 |
Most recent ldl-c >= 100 mg/dl |
| G8598 |
Asa/antiplat ther used |
Aspirin or another antiplatelet therapy used |
| G8599 |
No asa/antiplat ther use rng |
Aspirin or another antiplatelet therapy not used, reason not given |
| G8600 |
Tpa initi w/in 4.5 hr |
Iv thrombolytic therapy initiated within 4.5 hours (<= 270 minutes) of time last known well |
| G8601 |
No elig tpa init w/in 4.5 hr |
Iv thrombolytic therapy not initiated within 4.5 hours (<= 270 minutes) of time last known well for reasons documented by clinician (e.g. patient enrolled in clinical trial for stroke, patient admitted for elective carotid intervention) |
| G8602 |
No tpa init w/in 4.5 hr |
Iv thrombolytic therapy not initiated within 4.5 hours (<= 270 minutes) of time last known well, reason not given |
| G8627 |
Surg proc w/in 30 days |
Surgical procedure performed within 30 days following cataract surgery for major complications (e.g., retained nuclear fragments, endophthalmitis, dislocated or wrong power iol, retinal detachment, or wound dehiscence) |
| G8628 |
No surg proc w/in 30 days |
Surgical procedure not performed within 30 days following cataract surgery for major complications (e.g., retained nuclear fragments, endophthalmitis, dislocated or wrong power iol, retinal detachment, or wound dehiscence) |
| G8629 |
Doc antibio order b/4 surg |
Documentation of order for prophylactic parenteral antibiotic to be given within one hour (if fluoroquinolone or vancomycin, two hours) prior to surgical incision (or start of procedure when no incision is required) |
| G8630 |
Doc antibio given b/4 surg |
Documentation that administration of prophylactic parenteral antibiotics was initiated within one hour (if fluoroquinolone or vancomycin, two hours) prior to surgical incision (or start of procedure when no incision is required), as ordered |
| G8631 |
Pt no elg 4 order antbi give |
Clinician documented that patient was not an eligible candidate for ordering prophylactic parenteral antibiotics to be given within one hour (if fluoroquinolone or vancomycin, two hours) prior to surgical incision (or start of procedure when no incision is required) |
| G8632 |
Doc no antibi order b/4 surg |
Prophylactic parenteral antibiotics were not ordered to be given or given within one hour (if fluoroquinolone or vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required), reason not given |
| G8633 |
Pharm ther osteo rx |
Pharmacologic therapy (other than minerals/vitamins) for osteoporosis prescribed |
| G8634 |
Pt no elg phar ther osteo |
Clinician documented patient not an eligible candidate to receive pharmacologic therapy for osteoporosis |
| G8635 |
No pharm ther osteo rx |
Pharmacologic therapy for osteoporosis was not prescribed, reason not given |
| G8645 |
Asthma measures grp |
I intend to report the asthma measures group |
| G8646 |
Asthma mg qual act perform |
All quality actions for the applicable measures in the asthma measures group have been performed for this patient |
| G8647 |
Rafscrs ki scor >= 0 |
Residual score for the knee impairment successfully calculated and the score was equal to zero (0) or greater than zero (> 0) |
| G8648 |
Rafscrs ki scor < 0 |
Residual score for the knee impairment successfully calculated and the score was less than zero (< 0) |
| G8649 |
Rafscrs ki no scor |
Risk-adjusted functional status change residual score for the knee impairment not measured because the patient did not complete the fs status survey near discharge, patient not appropriate |
| G8650 |
Rafs crs ki no scor no rsn |
Residual score for the knee impairment not measured because the patient did not complete the lepf prom at initial evaluation and/or near discharge, reason not given |
| G8651 |
Rafscrs hi scor >=0 |
Residual score for the hip impairment successfully calculated and the score was equal to zero (0) or greater than zero (> 0) |
| G8652 |
Rafscrs hi scor < 0 |
Residual score for the hip impairment successfully calculated and the score was less than zero (< 0) |
| G8653 |
Rafscrs hi no scor |
Risk-adjusted functional status change residual scores for the hip impairment not measured because the patient did not complete the fs status survey near discharge, patient not appropriate |
| G8654 |
Rafs crs hi no scor no surv |
Residual score for the hip impairment not measured because the patient did not complete the lepf prom at initial evaluation and/or near discharge, reason not given |
| G8655 |
Rafscrs llfai scor >= 0 |
Residual score for the lower leg, foot or ankle impairment successfully calculated and the score was equal to zero (0) or greater than zero ( > 0) |
| G8656 |
Rafscrs llfai scor < 0 |
Residual score for the lower leg, foot or ankle impairment successfully calculated and the score was less than zero (< 0) |
| G8657 |
Rafscrs llfai no scor |
Risk-adjusted functional status change residual score for the lower leg, foot or ankle impairment not measured because the patient did not complete the fs status survey near discharge, patient not appropriate |
| G8658 |
Rafscrs llfai no scor + surv |
Residual score for the lower leg, foot or ankle impairment not measured because the patient did not complete the lepf prom at initial evaluation and/or near discharge, reason not given |
| G8659 |
Rafscrs lbi scor >= 0 |
Residual score for the low back impairment successfully calculated and the score was equal to zero (0) or greater than zero (> 0) |
| G8660 |
Rafscrs lbi scor < 0 |
Residual score for the low back impairment successfully calculated and the score was less than zero (< 0) |
| G8661 |
Rafscrs lbi no scor |
Risk-adjusted functional status change residual score for the low back impairment not measured because the patient did not complete the fs status survey near discharge, patient not appropriate |
| G8662 |
Rafs crs lbi no scor no surv |
Residual score for the low back impairment not measured because the patient did not complete the low back fs prom at initial evaluation and/or near discharge, reason not given |
| G8663 |
Rafscrs si scor >= 0 |
Residual score for the shoulder impairment successfully calculated and the score was equal to zero (0) or greater than zero (> 0) |
| G8664 |
Rafscrs si scor < 0 |
Residual score for the shoulder impairment successfully calculated and the score was less than zero (< 0) |
| G8665 |
Rafscrs si no scor |
Risk-adjusted functional status change residual score for the shoulder impairment not measured because the patient did not complete the fs status survey near discharge, patient not appropriate |
| G8666 |
Rafs crs si no scor no surv |
Residual score for the shoulder impairment not measured because the patient did not complete the shoulder fs prom at initial evaluation and/or near discharge, reason not given |
| G8667 |
Rafscrs ewh scor >= 0 |
Residual score for the elbow, wrist or hand impairment successfully calculated and the score was equal to zero (0) or greater than zero (> 0) |
| G8668 |
Rafscrs ewh scor < 0 |
Residual score for the elbow, wrist or hand impairment successfully calculated and the score was less than zero (< 0) |
| G8669 |
Rafscrs |
Risk-adjusted functional status change residual score for the elbow, wrist or hand impairment not measured because the patient did not complete the fs status survey near discharge, patient not appropriate |
| G8670 |
Rafs crs ewh no scor no surv |
Residual score for the elbow, wrist or hand impairment not measured because the patient did not complete the elbow/wrist/hand fs prom at initial evaluation and/or near discharge, reason not given |
| G8671 |
Rafscrs goi scor >= 0 |
Risk-adjusted functional status change residual score for the neck, cranium, mandible, thoracic spine, ribs or other general orthopedic impairment successfully calculated and the score was equal to zero (0) or greater than zero (> 0) |
| G8672 |
Rafscrs goi scor < 0 |
Risk-adjusted functional status change residual score for the neck, cranium, mandible, thoracic spine, ribs or other general orthopedic impairment successfully calculated and the score was less than zero (< 0) |
| G8673 |
Rafscrs goi no scor |
Risk-adjusted functional status change residual score for the neck, cranium, mandible, thoracic spine, ribs or other general orthopedic impairment not measured because the patient did not complete the fs status survey near discharge, patient not appropriate |
| G8674 |
Rafscrs neck, no msr/no foto |
Risk-adjusted functional status change residual score for the neck, cranium, mandible, thoracic spine, ribs or other general orthopedic impairment not measured because the patient did not complete the general orthopedic fs prom at initial evaluation and/or near discharge, reason not given |
| G8682 |
Lvg test perf |
Lvf testing documented as being performed prior to discharge or in the previous 12 months |
| G8683 |
Pt not elig for lvf test |
Lvf testing not performed prior to discharge or in the previous 12 months for a medical or patient documented reason |
| G8685 |
Lvf test not perf |
Lvf testing not documented as being performed prior to discharge or in the previous 12 months, reason not given |
| G8694 |
Lvef <=40% |
Left ventricular ejection fraction (lvef) < = 40% or documentation of moderate or severe lvsd |
| G8696 |
Antithromb thx presc |
Antithrombotic therapy prescribed at discharge |
| G8697 |
Antithromb no presc doc reas |
Antithrombotic therapy not prescribed for documented reasons (e.g., patient had stroke during hospital stay, patient expired during inpatient stay, other medical reason(s)); (e.g., patient left against medical advice, other patient reason(s)) |
| G8698 |
Antithromb no presc no reas |
Antithrombotic therapy was not prescribed at discharge, reason not given |
| G8699 |
Rehab ordered disch |
Rehabilitation services (occupational, physical or speech) ordered at or prior to discharge |
| G8700 |
Rehab not indicated disch |
Rehabilitation services (occupational, physical or speech) not indicated at or prior to discharge |
| G8701 |
Rehab not ordered |
Rehabilitation services were not ordered, reason not otherwise specified |
| G8702 |
Antiobiotics 4 hr prior surg |
Documentation that prophylactic antibiotics were given within 4 hours prior to surgical incision or intraoperatively |
| G8703 |
Antibiotics not prior surg |
Documentation that prophylactic antibiotics were neither given within 4 hours prior to surgical incision nor intraoperatively |
| G8704 |
Ecg performed |
12-lead electrocardiogram (ecg) performed |
| G8705 |
Med reas no ecg |
Documentation of medical reason(s) for not performing a 12-lead electrocardiogram (ecg) |
| G8706 |
Pt reas no ecg |
Documentation of patient reason(s) for not performing a 12-lead electrocardiogram (ecg) |
| G8707 |
Ecg not performed |
12-lead electrocardiogram (ecg) not performed, reason not given |
| G8708 |
Antibiotic not pres |
Patient not prescribed antibiotic |
| G8709 |
Uri ep compete diag |
Uri episodes when the patient had competing diagnoses on or three days after the episode date (e.g., intestinal infection, pertussis, bacterial infection, lyme disease, otitis media, acute sinusitis, acute pharyngitis, acute tonsillitis, chronic sinusitis, infection of the pharynx/larynx/tonsils/adenoids, prostatitis, cellulitis, mastoiditis, or bone infections, acute lymphadenitis, impetigo, skin staph infections, pneumonia/gonococcal infections, venereal disease (syphilis, chlamydia, inflammatory diseases [female reproductive organs]), infections of the kidney, cystitis or uti, and acne) |
| G8710 |
Pt pres antibiotic |
Patient prescribed antibiotic |
| G8711 |
Pres antibx on/within 3 day |
Prescribed antibiotic on or within 3 days after the episode date |
| G8712 |
Not pres antibiotic |
Antibiotic not prescribed or dispensed |
| G8713 |
Spkt/v great 1.2 kt/v |
Spkt/v greater than or equal to 1.2 (single-pool clearance of urea [kt] / volume [v]) |
| G8714 |
Hemodialysis 3 times week |
Hemodialysis treatment performed exactly three times per week for > 90 days |
| G8717 |
Less 1.2 kt/v |
Spkt/v less than 1.2 (single-pool clearance of urea [kt] / volume [v]), reason not given |
| G8718 |
Great 1.7 kt/v per week |
Total kt/v greater than or equal to 1.7 per week (total clearance of urea [kt] / volume [v]) |
| G8720 |
Less 1.7 kt/v per week |
Total kt/v less than 1.7 per week (total clearance of urea [kt] / volume [v]) |
| G8721 |
Pt, pn, hist grade doc |
Pt category (primary tumor), pn category (regional lymph nodes), and histologic grade were documented in pathology report |
| G8722 |
Med reas pt, pn, not doc |
Documentation of medical reason(s) for not including the pt category, the pn category or the histologic grade in the pathology report (e.g., re-excision without residual tumor; non-carcinomasanal canal) |
| G8723 |
Spec sit not prim tumor |
Specimen site is other than anatomic location of primary tumor |
| G8724 |
Pt, pn, hist grade not doc |
Pt category, pn category and histologic grade were not documented in the pathology report, reason not given |
| G8725 |
Lipid profile perf doc |
Fasting lipid profile performed (triglycerides, ldl-c, hdl-c and total cholesterol) |
| G8726 |
Doc reas no lipid profile |
Clinician has documented reason for not performing fasting lipid profile (e.g., patient declined, other patient reasons) |
| G8728 |
Lipid profile not perf |
Fasting lipid profile not performed, reason not given |
| G8730 |
Pain doc pos and plan |
Pain assessment documented as positive using a standardized tool and a follow-up plan is documented |
| G8731 |
Pain neg no plan |
Pain assessment using a standardized tool is documented as negative, no follow-up plan required |
| G8732 |
No doc of pain |
No documentation of pain assessment, reason not given |
| G8733 |
Doc pos elder mal scrn plan |
Elder maltreatment screen documented as positive and a follow-up plan is documented |
| G8734 |
Doc neg eld req |
Elder maltreatment screen documented as negative, follow-up is not required |
| G8735 |
Eld mal scrn pos no plan |
Elder maltreatment screen documented as positive, follow-up plan not documented, reason not given |
| G8736 |
Ldl-c <100mg/dl |
Most current ldl-c <100mg/dl |
| G8737 |
Ldl-c >=100mg/dl |
Most current ldl-c >=100mg/dl |
| G8738 |
Lvef < 40% |
Left ventricular ejection fraction (lvef) < 40% or documentation of severely or moderately depressed left ventricular systolic function |
| G8739 |
Lvef >= 40% |
Left ventricular ejection fraction (lvef) >= 40% or documentation as normal or mildly depressed left ventricular systolic function |
| G8740 |
Lvef not perfrmd |
Left ventricular ejection fraction (lvef) not performed or assessed, reason not given |
| G8749 |
No signs melanoma |
Absence of signs of melanoma (tenderness, jaundice, localized neurologic signs such as weakness, or any other sign suggesting systemic spread) or absence of symptoms of melanoma (cough, dyspnea, pain, paresthesia, or any other symptom suggesting the possibility of systemic spread of melanoma) |
| G8751 |
Smkg status not assess |
Smoking status and exposure to second hand smoke in the home not assessed, reason not given |
| G8752 |
Sys bp less 140 |
Most recent systolic blood pressure < 140 mmhg |
| G8753 |
Sys bp > or = 140 |
Most recent systolic blood pressure >= 140 mmhg |
| G8754 |
Dias bp less 90 |
Most recent diastolic blood pressure < 90 mmhg |
| G8755 |
Dias bp > or = 90 |
Most recent diastolic blood pressure >= 90 mmhg |
| G8756 |
No bp measure doc |
No documentation of blood pressure measurement, reason not given |
| G8757 |
Copd mg qual act perform |
All quality actions for the applicable measures in the chronic obstructive pulmonary disease (copd) measures group have been performed for this patient |
| G8758 |
Ibd mg qual act perform |
All quality actions for the applicable measures in the inflammatory bowel disease (ibd) measures group have been performed for this patient |
| G8759 |
Osa mg qual act perform |
All quality actions for the applicable measures in the sleep apnea measures group have been performed for this patient |
| G8761 |
Dementia mg qual act perform |
All quality actions for the applicable measures in the dementia measures group have been performed for this patient |
| G8762 |
Pd mg qual act perform |
All quality actions for the applicable measures in the parkinson's disease measures group have been performed for this patient |
| G8763 |
Hyperten mg qual act perform |
All quality actions for the applicable measures in the hypertension (htn) measures group have been performed for this patient |
| G8764 |
Car prev mg qual act perform |
All quality actions for the applicable measures in the cardiovascular prevention measures group have bee performed for this patient |
| G8765 |
Cataract mg qual act perform |
All quality actions for the applicable measures in the cataract measures group have been performed for this patient |
| G8767 |
Lipid panel res doc rev |
Lipid panel results documented and reviewed (must include total cholesterol, hdl-c, triglycerides and calculated ldl-c) |
| G8768 |
Doc med reas no lipid profle |
Documentation of medical reason(s) for not performing lipid profile (e.g., patients with palliative goals or for whom treatment of hypertension with standard treatment goals is not clinically appropriate) |
| G8769 |
Lipid profile not perform |
Lipid profile not performed, reason not given |
| G8770 |
Urine protein test doc rev |
Urine protein test result documented and reviewed |
| G8771 |
Doc dx ckd |
Documentation of diagnosis of chronic kidney disease |
| G8772 |
Doc med reas no urine protn |
Documentation of medical reason(s) for not performing urine protein test (e.g., patients with palliative goals or for whom treatment of hypertension with standard treatment goals is not cllinically appropriate) |
| G8773 |
No urine protein test |
Urine protein test was not performed, reason not given |
| G8774 |
Serum creatinine doc rev |
Serum creatinine test result documented and reviewed |
| G8775 |
Doc med reas no serum crtn |
Documentation of medical reason(s) for not performing serum creatinine test (e.g., patients with palliative goals or for whom treatment of hypertension with standard treatment goals is not clinically appropriate) |
| G8776 |
No serum creatinine test |
Serum creatinine test not performed, reason not given |
| G8777 |
Diabetes screen |
Diabetes screening test performed |
| G8778 |
Doc med reas no diabete scrn |
Documentation of medical reason(s) for not performing diabetes screening test (e.g., patients with a diagnosis of diabetes, or with palliative goals or for whom treatment of hypertension with standard treatment goals is not clinically appropriate) |
| G8779 |
No diabetes screen |
Diabetes screening test not performed, reason not given |
| G8780 |
Counsel diet phys activity |
Counseling for diet and physical activity performed |
| G8781 |
Doc med reas no counsel diet |
Documentation of medical reason(s) for patient not receiving counseling for diet and physical activity (e.g., patients with palliative goals or for whom treatment of hypertension with standard treatment goals is not clinically appropriate) |
| G8782 |
No counsel diet phys act |
Counseling for diet and physical activity not performed, reason not given |
| G8783 |
Bp scrn perf rec interval |
Normal blood pressure reading documented, follow-up not required |
| G8784 |
Pt no elig for bp assess |
Patient not eligible (e.g., documentation the patient is not eligible due to active diagnosis of hypertension, patient refuses, urgent or emergent situation) |
| G8785 |
Bp scrn no perf at interval |
Blood pressure reading not documented, reason not given |
| G8797 |
Specimen site not esophagus |
Specimen site other than anatomic location of esophagus |
| G8798 |
Specimen site not prostate |
Specimen site other than anatomic location of prostate |
| G8806 |
Perf ultrsnd to lct preg doc |
Performance of trans-abdominal or trans-vaginal ultrasound and pregnancy location documented |
| G8807 |
No ta tv ultrasnd |
Trans-abdominal or trans-vaginal ultrasound not performed for reasons documented by clinician (e.g., patient has a documented intrauterine pregnancy [iup]) |
| G8808 |
Ultrasound not perf, rng |
Trans-abdominal or trans-vaginal ultrasound not performed, reason not given |
| G8809 |
Rh-immunoglobulin order |
Rh-immunoglobulin (rhogam) ordered |
| G8810 |
Doc reas no rh-immuno |
Rh-immunoglobulin (rhogam) not ordered for reasons documented by clinician (e.g., patient had prior documented receipt of rhogam within 12 weeks, patient refusal) |
| G8811 |
No rh-immunoglobulin order |
Documentation rh-immunoglobulin (rhogam) was not ordered, reason not given |
| G8815 |
Doc reas no statin therapy |
Documented reason in the medical records for why the statin therapy was not prescribed (i.e., lower extremity bypass was for a patient with non-artherosclerotic disease) |
| G8816 |
Statin med pres at disch |
Statin medication prescribed at discharge |
| G8817 |
Doc reas no statin med disch |
Statin therapy not prescribed at discharge, reason not given |
| G8818 |
Pt disch to home by day#7 |
Patient discharge to home no later than post-operative day #7 |
| G8825 |
Pt not disch to home day#7 |
Patient not discharged to home by post-operative day #7 |
| G8826 |
Pt disch home day #2 evar |
Patient discharged to home no later than post-operative day #2 following evar |
| G8833 |
Pt not disch home day#2 evar |
Patient not discharged to home by post-operative day #2 following evar |
| G8834 |
Pt disch home day #2 cea |
Patient discharged to home no later than post-operative day #2 following cea |
| G8838 |
Not disch home by day #2 |
Patient not discharged to home by post-operative day #2 following cea |
| G8839 |
Sleep apnea assess |
Sleep apnea symptoms assessed, including presence or absence of snoring and daytime sleepiness |
| G8840 |
Doc reas no sleep apnea |
Documentation of reason(s) for not documenting an assessment of sleep symptoms (e.g., patient didn't have initial daytime sleepiness, patient visited between initial testing and initiation of therapy) |
| G8841 |
No sleep apnea assess |
Sleep apnea symptoms not assessed, reason not given |
| G8842 |
Ahi or rdi initial dx |
Apnea hypopnea index (ahi), respiratory disturbance index (rdi) or respiratory event index (rei) documented or measured within 2 months of initial evaluation for suspected obstructive sleep apnea |
| G8843 |
Doc reas no ahi or rdi |
Documentation of reason(s) for not measuring an apnea hypopnea index (ahi), a respiratory disturbance index (rdi), or a respiratory event index (rei) within 2 months of initial evaluation for suspected obstructive sleep apnea (e.g., medical, neurological, or psychiatric disease that prohibits successful completion of a sleep study, patients for whom a sleep study would present a bigger risk than benefit or would pose an undue burden, dementia, patients who decline ahi/rdi/rei measurement, patients who had a financial reason for not completing testing, test was ordered but not completed, patients decline because their insurance (payer) does not cover the expense)) |
| G8844 |
No ahi or rdi initial dx |
Apnea hypopnea index (ahi), respiratory disturbance index (rdi), or respiratory event index (rei) not documented or measured within 2 months of initial evaluation for suspected obstructive sleep apnea, reason not given |
| G8845 |
Pos airway press prescribed |
Positive airway pressure therapy prescribed |
| G8846 |
Mod or severe osa |
Moderate or severe obstructive sleep apnea (apnea hypopnea index (ahi) or respiratory disturbance index (rdi) of 15 or greater) |
| G8848 |
Mild osa |
Mild obstructive sleep apnea (apnea hypopnea index (ahi) or respiratory disturbance index (rdi) of less than 15) |
| G8849 |
Doc reas no pos air press |
Documentation of reason(s) for not prescribing positive airway pressure therapy (e.g., patient unable to tolerate, alternative therapies use, patient declined, financial, insurance coverage) |
| G8850 |
No pap prescribed |
Positive airway pressure therapy not prescribed, reason not given |
| G8851 |
Adhere tx assess at lst ann |
Adherence to therapy was assessed at least annually through an objective informatics system or through self-reporting (if objective reporting is not available, documented) |
| G8852 |
Pos air press prescribe |
Positive airway pressure therapy was prescribed |
| G8853 |
Pos air press not prescribe |
Positive airway pressure therapy not prescribed |
| G8854 |
Reas no adhere therapy |
Documentation of reason(s) for not objectively reporting adherence to evidence-based therapy (e.g., patients who have been diagnosed with a terminal or advanced disease with an expected life span of less than 6 months, patients who decline therapy, patients who do not return for follow-up at least annually, patients unable to access/afford therapy, patient's insurance will not cover therapy) |
| G8855 |
Ther not assessed annually |
Adherence to therapy was not assessed at least annually through an objective informatics system or through self-reporting (if objective reporting is not available), reason not given |
| G8856 |
Ref for oto eval |
Referral to a physician for an otologic evaluation performed |
| G8857 |
No elig ref for oto eval |
Patient is not eligible for the referral for otologic evaluation measure (e.g., patients who are already under the care of a physician for acute or chronic dizziness) |
| G8858 |
Not ref for oto eval |
Referral to a physician for an otologic evaluation not performed, reason not given |
| G8859 |
Corticosteroids 10mg 60 days |
Patient receiving corticosteroids greater than or equal to 10mg/day for 60 or greater consecutive days |
| G8860 |
Corticosteroid 10 mg 60 days |
Patients who have received dose of corticosteroids greater than or equal to 10mg/day for 60 or greater consecutive days |
| G8861 |
Dxa ordered for osteo |
Within the past 2 years, central dual-energy x-ray absorptiometry (dxa) ordered and documented, review of systems and medication history or pharmacologic therapy (other than minerals/vitamins) for osteoporosis prescribed |
| G8862 |
No corticostrd 10mg 60 days |
Patients not receiving corticosteroids greater than or equal to 10mg/day for 60 or greater consecutive days |
| G8863 |
No assess bone loss |
Patients not assessed for risk of bone loss, reason not given |
| G8864 |
Pneumococcal vaccine admin |
Pneumococcal vaccine administered or previously received |
| G8865 |
Doc med reas no pneumococcal |
Documentation of medical reason(s) for not administering or previously receiving pneumococcal vaccine (e.g., patient allergic reaction, potential adverse drug reaction) |
| G8866 |
Doc pt reas no pneumococcal |
Documentation of patient reason(s) for not administering or previously receiving pneumococcal vaccine (e.g., patient refusal) |
| G8867 |
No pneumococcal admin |
Pneumococcal vaccine not administered or previously received, reason not given |
| G8868 |
1st course antitnf |
Patients receiving a first course of anti-tnf therapy |
| G8869 |
Doc immune hep b antitnf |
Patient has documented immunity to hepatitis b and initiating anti-tnf therapy |
| G8870 |
Hepb admin 1st antitnf |
Hepatitis b vaccine injection administered or previously received and is receiving a first course of anti-tnf therapy |
| G8871 |
No 1st antitnf |
Patient not receiving a first course of anti-tnf therapy |
| G8872 |
Intraop image confirm excise |
Excised tissue evaluated by imaging intraoperatively to confirm successful inclusion of targeted lesion |
| G8873 |
Specimen not intraop image |
Patients with needle localization specimens which are not amenable to intraoperative imaging such as mri needle wire localization, or targets which are tentatively identified on mammogram or ultrasound which do not contain a biopsy marker but which can be verified on intraoperative inspection or pathology (e.g., needle biopsy site where the biopsy marker is remote from the actual biopsy site) |
| G8874 |
Tissue not image intraop |
Excised tissue not evaluated by imaging intraoperatively to confirm successful inclusion of targeted lesion |
| G8875 |
Breast cancer dx min invsive |
Clinician diagnosed breast cancer preoperatively by a minimally invasive biopsy method |
| G8876 |
Doc reas no min inv dx |
Documentation of reason(s) for not performing minimally invasive biopsy to diagnose breast cancer preoperatively (e.g., lesion too close to skin, implant, chest wall, etc., lesion could not be adequately visualized for needle biopsy, patient condition prevents needle biopsy [weight, breast thickness, etc.], duct excision without imaging abnormality, prophylactic mastectomy, reduction mammoplasty, excisional biopsy performed by another physician) |
| G8877 |
No brst cncr dx min invasive |
Clinician did not attempt to achieve the diagnosis of breast cancer preoperatively by a minimally invasive biopsy method, reason not given |
| G8878 |
Sent lymph node biopsy |
Sentinel lymph node biopsy procedure performed |
| G8879 |
Node neg inv brst cncr |
Clinically node negative (t1n0m0 or t2n0m0) invasive breast cancer |
| G8880 |
Sen lym p node biop not perf |
Documentation of reason(s) sentinel lymph node biopsy not performed (e.g., reasons could include but not limited to; non-invasive cancer, incidental discovery of breast cancer on prophylactic mastectomy, incidental discovery of breast cancer on reduction mammoplasty, pre-operative biopsy proven lymph node (ln) metastases, inflammatory carcinoma, stage 3 locally advanced cancer, recurrent invasive breast cancer, clinically node positive after neoadjuvant systemic therapy, patient refusal after informed consent, patient with significant age, comorbidities, or limited life expectancy and favorable tumor; adjuvant systemic therapy unlikely to change) |
| G8881 |
Brst cncr stage > t1n0m0 |
Stage of breast cancer is greater than t1n0m0 or t2n0m0 |
| G8882 |
No sent lymph node biopsy |
Sentinel lymph node biopsy procedure not performed, reason not given |
| G8883 |
Rev, comm, track, doc biopsy |
Biopsy results reviewed, communicated, tracked and documented |
| G8884 |
Doc reas biopsy not review |
Clinician documented reason that patient's biopsy results were not reviewed |
| G8885 |
No rev, comm, track biopsy |
Biopsy results not reviewed, communicated, tracked or documented |
| G8886 |
Bp under control |
Most recent blood pressure under control |
| G8887 |
Doc med reas bp not control |
Documentation of medical reason(s) for most recent blood pressure not being under control (e.g., patients with palliative goals or for whom treatment of hypertension with standard treatment goals is not clinically appropriate) |
| G8888 |
Bp not under control |
Most recent blood pressure not under control, results documented and reviewed |
| G8889 |
No doc bp |
No documentation of blood pressure measurement, reason not given |
| G8890 |
Ldl-c under control |
Most recent ldl-c under control, results documented and reviewed |
| G8891 |
Doc med reas no ldl-c contrl |
Documentation of medical reason(s) for most recent ldl-c not under control (e.g., patients with palliative goals for whom treatment of hypertension with standard treatment goals is not clinically appropriate) |
| G8892 |
Doc med reas no ldl-c test |
Documentation of medical reason(s) for not performing ldl-c test (e.g. patients with palliative goals or for whom treatment of hypertension with standard treatment goals is not clinically appropriate) |
| G8893 |
Ldl-c not under control |
Most recent ldl-c not under control, results documented and reviewed |
| G8894 |
Ldl-c not performed |
Ldl-c not performed, reason not given |
| G8895 |
Antrom prescribe |
Oral aspirin or other antithrombotic therapy prescribed |
| G8896 |
Doc med reas no antihtrom |
Documentation of medical reason(s) for not prescribing oral aspirin or other antithrombotic therapy (e.g., patient documented to be low risk or patient with terminal illness or treatment of hypertension with standard treatment goals is not clinically appropriate, or for whom risk of aspirin or other antithrombotic therapy exceeds potential benefits such as for individuals whose blood pressure is poorly controlled) |
| G8897 |
Antithrom not prescribe |
Oral aspirin or other antithrombotic therapy was not prescribed, reason not given |
| G8898 |
Copd measures group |
I intend to report the chronic obstructive pulmonary disease (copd) measures group |
| G8899 |
Inflammatory bowel dis mg |
I intend to report the inflammatory bowel disease (ibd) measures group |
| G8900 |
Obstructive sleep apnea mg |
I intend to report the sleep apnea measures group |
| G8902 |
Dementia measures group |
I intend to report the dementia measures group |
| G8903 |
Parkinson's disease mg |
I intend to report the parkinson's disease measures group |
| G8904 |
Hypertension mg |
I intend to report the hypertension (htn) measures group |
| G8905 |
Cardiovascular prevention mg |
I intend to report the cardiovascular prevention measures group |
| G8906 |
Cataract measures group |
I intend to report the cataract measures group |
| G8907 |
Pt doc no events on discharg |
Patient documented not to have experienced any of the following events: a burn prior to discharge; a fall within the facility; wrong site/side/patient/procedure/implant event; or a hospital transfer or hospital admission upon discharge from the facility |
| G8908 |
Pt doc w burn prior to d/c |
Patient documented to have received a burn prior to discharge |
| G8909 |
Pt doc no burn prior to d/c |
Patient documented not to have received a burn prior to discharge |
| G8910 |
Pt doc to have fall in asc |
Patient documented to have experienced a fall within asc |
| G8911 |
Pt doc no fall in asc |
Patient documented not to have experienced a fall within ambulatory surgical center |
| G8912 |
Pt doc with wrong event |
Patient documented to have experienced a wrong site, wrong side, wrong patient, wrong procedure or wrong implant event |
| G8913 |
Pt doc no wrong event |
Patient documented not to have experienced a wrong site, wrong side, wrong patient, wrong procedure or wrong implant event |
| G8914 |
Pt trans to hosp post d/c |
Patient documented to have experienced a hospital transfer or hospital admission upon discharge from asc |
| G8915 |
Pt not trans to hosp at d/c |
Patient documented not to have experienced a hospital transfer or hospital admission upon discharge from asc |
| G8916 |
Pt w iv ab given on time |
Patient with preoperative order for iv antibiotic surgical site infection (ssi) prophylaxis, antibiotic initiated on time |
| G8917 |
Pt w iv ab not given on time |
Patient with preoperative order for iv antibiotic surgical site infection (ssi) prophylaxis, antibiotic not initiated on time |
| G8918 |
Pt w/o preop order iv ab pro |
Patient without preoperative order for iv antibiotic surgical site infection (ssi) prophylaxis |
| G8923 |
Lvef <= 40% or lvsd |
Left ventricular ejection fraction (lvef) <= 40% or documentation of moderately or severely depressed left ventricular systolic function |
| G8924 |
Spir res doc fev1/fvc<70% |
Spirometry results documented (fev1/fvc < 70%) |
| G8925 |
Spir fev1/fvc>=60% & no copd |
Spirometry test results demonstrate fev1 >= 60% fev1/fvc >= 70%, predicted or patient does not have copd symptoms |
| G8926 |
Spiro no perf or doc |
Spirometry test not performed or documented, reason not given |
| G8927 |
Adj chem pres ajcc iii |
Adjuvant chemotherapy referred, prescribed or previously received for ajcc stage iii, colon cancer |
| G8928 |
Adj chem not pres rsn spec |
Adjuvant chemotherapy not prescribed or previously received, for documented reasons (e.g., medical co-morbidities, diagnosis date more than 5 years prior to the current visit date, patient's diagnosis date is within 120 days of the end of the 12 month reporting period, patient's cancer has metastasized, medical contraindication/allergy, poor performance status, other medical reasons, patient refusal, other patient reasons, patient is currently enrolled in a clinical trial that precludes prescription of chemotherapy, other system reasons) |
| G8929 |
Adj cmo not pres rsn not gvn |
Adjuvant chemotherapy not prescribed or previously received, reason not given |
| G8930 |
Assess of dep @ initial eval |
Assessment of depression severity at the initial evaluation |
| G8931 |
Asses of dep not documented |
Assessment of depression severity not documented, reason not given |
| G8932 |
Suicd rsk assessed init eval |
Suicide risk assessed at the initial evaluation |
| G8933 |
Suicide risk not assessed |
Suicide risk not assessed at the initial evaluation, reason not given |
| G8934 |
Lvef <=40% or dep lv sys fcn |
Left ventricular ejection fraction (lvef) <=40% or documentation of moderately or severely depressed left ventricular systolic function |
| G8935 |
Rx ace or arb therapy |
Clinician prescribed angiotensin converting enzyme (ace) inhibitor or angiotensin receptor blocker (arb) therapy |
| G8936 |
Pt not eligible ace/arb |
Clinician documented that patient was not an eligible candidate for angiotensin converting enzyme (ace) inhibitor or angiotensin receptor blocker (arb) therapy (eg, allergy, intolerance, pregnancy, renal failure due to ace inhibitor, diseases of the aortic or mitral valve, other medical reasons) or (eg, patient declined, other patient reasons) |
| G8937 |
No rx ace/arb therapy |
Clinician did not prescribe angiotensin converting enzyme (ace) inhibitor or angiotensin receptor blocker (arb) therapy, reason not given |
| G8938 |
Bmi doc onl fup nt doc |
Bmi is documented as being outside of normal parameters, follow-up plan is not documented, documentation the patient is not eligible |
| G8939 |
Pain as doc positive, no f/u |
Pain assessment documented as positive, follow-up plan not documented, documentation the patient is not eligible at the time of the encounter |
| G8940 |
Scr dep pos, no plan done |
Screening for depression documented as positive, a follow-up plan not completed, documented reason |
| G8941 |
Eld maltreatment doc as pos |
Elder maltreatment screen documented as positive, follow-up plan not documented, documentation the patient is not eligible for follow-up plan at the time of the encounter |
| G8942 |
Doc fcn/care plan w/30 days |
Functional outcome assessment using a standardized tool is documented within the previous 30 days and a care plan, based on identified deficiencies is documented within two days of the functional outcome assessment |
| G8943 |
Ldlc not pres w/i 12 mo prir |
Ldl-c result not present or not within 12 months prior |
| G8944 |
Ajcc mel cnr stg 0 - iic |
Ajcc melanoma cancer stage 0 through iic melanoma |
| G8946 |
Mibm but no dx of breast ca |
Minimally invasive biopsy method attempted but not diagnostic of breast cancer (e.g., high risk lesion of breast such as atypical ductal hyperplasia, lobular neoplasia, atypical lobular hyperplasia, lobular carcinoma in situ, atypical columnar hyperplasia, flat epithelial atypia, radial scar, complex sclerosing lesion, papillary lesion, or any lesion with spindle cells) |
| G8947 |
1 or more neuropsych |
One or more neuropsychiatric symptoms |
| G8948 |
No neuropsych symptoms |
No neuropsychiatric symptoms |
| G8949 |
Doc pt reas on counsel diet |
Documentation of patient reason(s) for patient not receiving counseling for diet and physical activity (e.g., patient is not willing to discuss diet or exercise interventions to help control blood pressure, or the patient said he/she refused to make these changes) |
| G8950 |
Pre-htn or htn doc, f/u indc |
Elevated or hypertensive blood pressure reading documented, and the indicated follow-up is documented |
| G8951 |
Pre-htn/htn doc, no pt f/u |
Pre-hypertensive or hypertensive blood pressure reading documented, indicated follow-up not documented, documentation the patient is not eligible |
| G8952 |
Pre-htn/htn, no f/u, not gvn |
Elevated or hypertensive blood pressure reading documented, indicated follow-up not documented, reason not given |
| G8953 |
Oncology mg qual act perform |
All quality actions for the applicable measures in the oncology measures group have been performed for this patient |
| G8955 |
Most recent assess vol mgmt |
Most recent assessment of adequacy of volume management documented |
| G8956 |
Pt rcv hedia outpt dyls fac |
Patient receiving maintenance hemodialysis in an outpatient dialysis facility |
| G8957 |
Pt no hedia in outpt fac |
Patient not receiving maintenance hemodialysis in an outpatient dialysis facility |
| G8958 |
Assess vol mgmt not doc |
Assessment of adequacy of volume management not documented, reason not given |
| G8959 |
Clin tx mdd comm to tx clin |
Clinician treating major depressive disorder communicates to clinician treating comorbid condition |
| G8960 |
Clin tx mdd not comm |
Clinician treating major depressive disorder did not communicate to clinician treating comorbid condition, reason not given |
| G8961 |
Csit lowrisk surg pts preop |
Cardiac stress imaging test primarily performed on low-risk surgery patient for preoperative evaluation within 30 days preceding this surgery |
| G8962 |
Csit on pt any reas 30 days |
Cardiac stress imaging test performed on patient for any reason including those who did not have low risk surgery or test that was performed more than 30 days preceding low risk surgery |
| G8963 |
Csi per asx pt w/pci 2 yrs |
Cardiac stress imaging performed primarily for monitoring of asymptomatic patient who had pci within 2 years |
| G8964 |
Csi any other than pci 2 yr |
Cardiac stress imaging test performed primarily for any other reason than monitoring of asymptomatic patient who had pci within 2 years (e.g., symptomatic patient, patient greater than 2 years since pci, initial evaluation, etc) |
| G8965 |
Csit perf on low chd rsk |
Cardiac stress imaging test primarily performed on low chd risk patient for initial detection and risk assessment |
| G8966 |
Csit perf sx or high chd rsk |
Cardiac stress imaging test performed on symptomatic or higher than low chd risk patient or for any reason other than initial detection and risk assessment |
| G8967 |
Warf or other fda drug presc |
Fda approved oral anticoagulant is prescribed |
| G8968 |
Doc med not presb |
Documentation of medical reason(s) for not prescribing an fda-approved anticoagulant (e.g., present or planned atrial appendage occlusion or ligation or patient being currently enrolled in a clinical trial related to af/atrial flutter treatment) |
| G8969 |
Doc pt rsn no presc warf/fda |
Documentation of patient reason(s) for not prescribing an oral anticoagulant that is fda approved for the prevention of thromboembolism (e.g., patient preference for not receiving anticoagulation) |
| G8970 |
No rsk fac or 1 mod risk te |
No risk factors or one moderate risk factor for thromboembolism |
| G8971 |
Warfrn or othr antcog no rx |
Warfarin or another oral anticoagulant that is fda approved not prescribed, reason not given |
| G8972 |
1>=risk or>= mod risk for te |
One or more high risk factors for thromboembolism or more than one moderate risk factor for thromboembolism |
| G8973 |
Mst rcnt hbb < 10g/dl |
Most recent hemoglobin (hgb) level < 10 g/dl |
| G8974 |
Hgb not doc rns not gvn |
Hemoglobin level measurement not documented, reason not given |
| G8975 |
Hgb <10g/dl, med rsn |
Documentation of medical reason(s) for patient having a hemoglobin level < 10 g/dl (e.g., patients who have non-renal etiologies of anemia [e.g., sickle cell anemia or other hemoglobinopathies, hypersplenism, primary bone marrow disease, anemia related to chemotherapy for diagnosis of malignancy, postoperative bleeding, active bloodstream or peritoneal infection], other medical reasons) |
| G8976 |
Hgb >= 10 g/dl |
Most recent hemoglobin (hgb) level >= 10 g/dl |
| G8977 |
Oncology measures grp |
I intend to report the oncology measures group |
| G8978 |
Mobility current status |
Mobility: walking & moving around functional limitation, current status, at therapy episode outset and at reporting intervals |
| G8979 |
Mobility goal status |
Mobility: walking & moving around functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting |
| G8980 |
Mobility d/c status |
Mobility: walking & moving around functional limitation, discharge status, at discharge from therapy or to end reporting |
| G8981 |
Body pos current status |
Changing & maintaining body position functional limitation, current status, at therapy episode outset and at reporting intervals |
| G8982 |
Body pos goal status |
Changing & maintaining body position functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting |
| G8983 |
Body pos d/c status |
Changing & maintaining body position functional limitation, discharge status, at discharge from therapy or to end reporting |
| G8984 |
Carry current status |
Carrying, moving & handling objects functional limitation, current status, at therapy episode outset and at reporting intervals |
| G8985 |
Carry goal status |
Carrying, moving and handling objects, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting |
| G8986 |
Carry d/c status |
Carrying, moving & handling objects functional limitation, discharge status, at discharge from therapy or to end reporting |
| G8987 |
Self care current status |
Self care functional limitation, current status, at therapy episode outset and at reporting intervals |
| G8988 |
Self care goal status |
Self care functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting |
| G8989 |
Self care d/c status |
Self care functional limitation, discharge status, at discharge from therapy or to end reporting |
| G8990 |
Other pt/ot current status |
Other physical or occupational therapy primary functional limitation, current status, at therapy episode outset and at reporting intervals |
| G8991 |
Other pt/ot goal status |
Other physical or occupational therapy primary functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting |
| G8992 |
Other pt/ot d/c status |
Other physical or occupational therapy primary functional limitation, discharge status, at discharge from therapy or to end reporting |
| G8993 |
Sub pt/ot current status |
Other physical or occupational therapy subsequent functional limitation, current status, at therapy episode outset and at reporting intervals |
| G8994 |
Sub pt/ot goal status |
Other physical or occupational therapy subsequent functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting |
| G8995 |
Sub pt/ot d/c status |
Other physical or occupational therapy subsequent functional limitation, discharge status, at discharge from therapy or to end reporting |
| G8996 |
Swallow current status |
Swallowing functional limitation, current status at therapy episode outset and at reporting intervals |
| G8997 |
Swallow goal status |
Swallowing functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting |
| G8998 |
Swallow d/c status |
Swallowing functional limitation, discharge status, at discharge from therapy or to end reporting |
| G8999 |
Motor speech current status |
Motor speech functional limitation, current status at therapy episode outset and at reporting intervals |