This article is for cardiologists, endocrinologists, primary care providers, and their billing staff
If your patient is eligible for statin therapy, help to support them by:
Statin therapy can help prevent cardiovascular events in patients with diabetes or atherosclerotic cardiovascular disease (ASCVD), but some may not be clinically appropriate to receive it. Use diagnosis codes to document patient conditions that prevent them from taking a statin.
Below we list the most common conditions and diagnosis codes that may prevent statin use.1 If a patient has one or more of the conditions listed below and can’t take a statin, code your claim with the appropriate diagnosis code.
For patients with this condition | Use the appropriate code |
---|---|
Cirrhosis | K70.30, K70.31, K71.7, K74.3, K74.4, K74.5, K74.60, K74.69, P78.81 |
Dialysis procedure | G0257, S9339, 90935, 90937, 90945, 90947, 90997, 90999, 99512, 3E1M39Z, 5A1D00Z, 5A1D60Z, 5A1D70Z, 5A1D80Z, 5A1D90Z |
End stage renal disease | N18.6, N18.5, Z99.2 |
Hospice care | G9473-G9479, Q5003-Q5010, S9126, T2042-T2046, G0182, 99377, 99378, REV code -0115, 0125, 0135, 0145, 0155, 0235, 0650-0659 |
IVF procedure | S4015, S4016, S4018, S4020, S4021 |
Myalgia2 | M79.1-M79.18 |
Myositis | M60.80-M60.819, M60.821-M60.829, M60.831-M60.839, M60.841-M60.849, M60.851-M60.859, M60.861-M60.869, M60.871-M60.879, M60.88-M60.9 |
Myopathy | G72.0, G72.2, G72.9 |
Rhabdomyolysis | M62.82 |
We review claims to determine which patients should be in HEDIS and 5-Star quality measures. When you code your claim using the most current diagnosis code, we’ll remove ineligible patients from these measures. This helps us determine possible gaps in care and may reduce our administrative requests for information.
As always, thank you for the care you provide to our members.
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