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.
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