This article is for cardiologists, endocrinologists, and primary care providers
Please share with your billing staff or agency
When patients with diabetes or heart disease have conditions that make it unsafe to take a statin, use diagnosis codes to note those conditions.
Common conditions that make statin therapy inappropriate
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.1
| 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 |
| Dialysis | Z99.2 |
| End Stage Renal Disease (ESRD) | I12.0, I13.11, I13.2, N18.5, N18.6, N19 |
| Hospice Enrollment | G9473-G9479 |
| Pregnancy, Lactation, & Fertility | Numerous |
| Myositis | M60.80, M60.819, M60.829, M60.839, M60.849, M60.859, M60.869, M60.879, M60.9 |
| Myopathy | G72.0, G72.89, G72.9 |
| Rhabdomyolysis | M62.82 |
| Polycystic Ovarian Syndrome (PCOS) | E28.2 |
| Pre-diabetes | R73.03, R73.09 |
Why it matters
We review claims to determine which patients should be in HEDIS and 5-Star quality measures. Coding your claim with the most current diagnosis code can help us:
- Reduce our administrative requests for information by removing ineligible patients from these measures
- Determine possible gaps in care
Actions you can take to improve statin adherence
Help to support your patients eligible for statin therapy by:
- Offering medication reminders and education
- Simplifying medication regimen by switching combinations or using alternate dosing, if possible
Thank you
Thank you for coding your claims in this way to help us correctly identify patients with these conditions.
About Star ratings: CMS rates Medicare Part D and Medicare Advantage plans on a scale from one to five stars based on certain quality and performance measures.
Footnotes
- Please note that there are many codes that may exclude members from statin quality measures; the list above is a sample of diagnosis and procedure codes that may be used.
MPC_040125-2G-4