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Document conditions that prevent patients from taking statins
June 28, 2023

This article is for cardiologists, endocrinologists, primary care providers, and their billing staff

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.

Common conditions that make statin therapy inappropriate

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
Dialysis procedure G0257
End stage renal disease N18.6
Hospice care G9473-G9479
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
Pregnancy G9778

What this means for you

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.

Thank you

As always, thank you for the care you provide to our members.

1. Please note this list is a sample of diagnosis codes that may be used.

2. We understand that statins may be critical therapy for certain patients with mild myalgias. We recommend that you work through a careful continuation plan with your patient.