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PAP226 - Category II CPT and SDoH ICD-10 CM Codes - Language revision; clarified Category II CPT code reporting requirements.
Effective date
Not stated in the notice
Identified
Sep 29, 2026
Summary
Blue Cross of Idaho clarified Category II CPT code reporting requirements in PAP226, emphasizing that these codes are optional supplemental tracking codes (not required for correct coding) used to close HEDIS quality gaps and document Social Determinants of Health (SDoH) Z codes. The policy reinforces that Category II CPT codes and supplemental diagnosis codes via CPT 99499 should always be billed with $0.00 or $0.01 charges respectively, and provides specific requirements for submitting supplemental diagnoses when the primary claim reaches the 12-diagnosis code maximum.
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What to do
Action · 7 steps
01Billing team must review and update internal procedures for Category II CPT code and supplemental diagnosis code submissions.
02Ensure billing system is configured to allow $0.00 charge entry for Category II CPT codes or use $0.01 if system prevents zero entry.
03Train billing staff that Category II CPT codes are OPTIONAL and not required for correct coding.
04Update claim submission workflow to recognize when primary E/M claims reach the 12-diagnosis code maximum, then submit CPT 99499 as a separate claim with remaining diagnosis codes (including SDoH Z codes Z55-Z65) at $0.01 charge.
05Verify that 99499 claims include only diagnosis codes with no other CPT codes attached, and do not include modifiers (except SC for vendor-administered prospective health assessments).
06Document in medical records all SDoH diagnoses with clinician sign-off before billing.
07Review policy history noting August 2026 language clarification and June 2025 addition of supplemental diagnosis section.
If missed: Failure to comply may result in claim denials or processing delays.
Codes mentioned
99499Z55Z56Z57Z58Z59Z60Z61Z62Z63Z64Z65
Original notice
PAP226 - Category II CPT and SDoH ICD-10 CM Codes - Language revision; clarified Category II CPT code reporting requirements.
providers.bcidaho.com · Always check the source before changing claims.
Related changes
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