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:

  1. Optimize proper documentation and monitoring care outcomes effectively.
  2. Minimize medical record request and maximize gaps in care closure and interventions.
  3. 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%

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)

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

3062F

Positive microalbuminuria test result documented and reviewed

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.

Updated March 23, 2022
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