Healthcare Effectiveness Data and Information Set (HEDIS) CPT II Coding
Healthcare Effectiveness Data and Information Set® (HEDIS®), is a set of more than 90 standardized performance measures used to annually evaluate and compare the performance of health plans. Data for these measures are collected using administrative/claims information and also Member medical record information. HEDIS results are used to identify opportunities for improving healthcare.
Why is using CPT II codes important?
Using Current Procedural Terminology (CPT II) when submitting claims can help you:
- Optimize proper documentation and monitoring care outcomes effectively.
- Minimize medical record request and maximize gaps in care closure and interventions.
- Improve communication and data capture across different settings of care.
Performance measures and corresponding code lists1:
Medication Reconciliation Post-discharge
Code |
Definition |
| 111F | Discharge medications reconciled with the current medication list in outpatient medical record |
Controlling Blood Pressure
Code |
Definition |
| 3078F | Most recent diastolic blood pressure less than 80 mm Hg |
| 3079F | Most recent diastolic blood pressure 80-89 mm Hg |
| 3080F | Most recent diastolic blood pressure greater than or equal to 90 mm Hg |
| 3074F | Most recent systolic blood pressure less than 130 mm Hg |
| 3075F | Most recent systolic blood pressure 130-139 mm Hg |
| 3077F | Most recent systolic blood pressure greater than or equal to 140 mm Hg |
Diabetes Care
Measure |
Code |
Definition |
| Blood Sugar Control-HbA1c | ||
|
3044F |
Most recent hemoglobin A1c (HbA1c) level less than 7.0% |
|
|
3051F |
Most recent hemoglobin A1c (HbA1c) level greater than or equal to 7.0% and less than 8.0% |
|
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3052F |
Most recent hemoglobin A1c (HbA1c) level greater than or equal to 8.0% and less than or equal to 9.0% |
|
|
3046F |
Most recent hemoglobin A1c level greater than 9.0% |
|
| Retinal Eye Exam | ||
|
2022F |
Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy (DM) |
|
|
2023F |
Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy (DM) | |
|
2024F |
7 standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy (DM) |
|
|
2025F |
7 standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy (DM) |
|
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2026F |
7 standard field stereoscopic retinal photos with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy (DM) |
|
|
2033F |
Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed; with evidence of retinopathy (DM) |
|
|
3072F |
Low risk for retinopathy (no evidence of retinopathy in the prior year) (DM) |
|
| Kidney Disease Monitoring | ||
|
3060F |
Positive microalbuminuria test result documented and reviewed |
|
|
3061F |
Negative microalbuminuria test result documented and reviewed |
|
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3062F |
Positive microalbuminuria test result documented and reviewed |
|
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3066F |
Documentation of treatment for nephropathy (e.g., patient receiving dialysis, patient being treated for ESRD, CRF, ARF, or renal insufficiency, any visit to a nephrologist) |
|
|
4010F |
Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) therapy prescribed or currently being taken |
Prenatal and Postpartum Care
Code |
Definition |
| 0500F | Initial prenatal care visit (report at first prenatal encounter with health care professional providing obstetrical care. Report also date of visit and, in a separate field, the date of the last menstrual period [LMP]) (Prenatal) |
| 0501F | Prenatal flow sheet documented in medical record by first prenatal visit (documentation includes at minimum blood pressure, weight, urine protein, uterine size, fetal heart tones, and estimated date of delivery). Report also: date of visit and, in a separate field, the date of the last menstrual period - LMP (Note: If reporting 0501F prenatal flow sheet, it is not necessary to report 0500F initial prenatal care visit) |
| 0502F | Subsequent prenatal care visit (Prenatal) [Excludes: patients who are seen for a condition unrelated to pregnancy or prenatal care (e.g., an upper respiratory infection; patients seen for consultation only, not for continuing care)] |
| 0503F | Postpartum care visit |
A HEDIS CPT II Coding quick reference guide including this information is located in the new Quick Reference Guide section under Documents, Resources, and bulletins. For additional information, or if you have any questions, please contact your Provider Engagement Consultant or Provider Support at 844.440.4629.