HEDIS^® CPT II Coding

Quick reference guide

What is HEDIS?

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
1111F	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

Blood sugar control - HbA1c

Code	Definition
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

Code	Definition
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	Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed; with evidence of retinopathy (DM)
2033F	Eye imaging validated to match diagnosis from 7 standard field stereoscopic retinal photos results documented and reviewed; without evidence of retinopathy (DM)
3072F	Low risk for retinopathy (no evidence of retinopathy in the prior year) (DM)

Kidney disease monitoring

Code	Definition
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

Need additional information?

Contact your provider engagement consultant or the provider service team at 844.440.4629.

¹ The list is periodically reviewed for new codes and is accurate as of February 2022.

Updated October 1, 2021
H9408_WBST22_M

Web Content Viewer - Metadata

Web Content Viewer - Fixed Context

Web Content Viewer

HEDIS® CPT II Coding

What is HEDIS?

Why is using CPT II codes important?

Performance measures and corresponding code lists1:

Web Content Viewer - Fixed Context

Web Content Viewer - Fixed Context

Web Content Viewer - Fixed Context

Blood sugar control - HbA1c

Retinal eye exam

Kidney disease monitoring

Web Content Viewer - Fixed Context

Web Content Viewer

Need additional information?

Web Content Viewer - Fixed Context

Web Content Viewer - Fixed Context

HEDIS^® CPT II Coding

Performance measures and corresponding code lists¹: