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Preventive Care Services (P)

PREVENTIVE CARE SERVICES

The following is a list of preventive services (HCP rider) along with the diagnoses and procedure codes that your health plan has determined to meet and in some situations exceed the requirements and recommendations issued by the Affordable Care Act. Your Health Plan will process these claims in a manner that is intended to comply with Section 1557 of the Affordable Care Act. Preventive services are still subject to medical management criteria.

Some or all of the contraceptives methods or prescription drugs listed may not be covered under your health plan because of the employer’s religious beliefs. To find out if contraceptives methods and prescriptions drugs are excluded, please contact Customer Service for additional information. 

**Services are still subject to Medical Management Criteria. **

 

 

*Blue represents coding updates.

DESCRIPTION

CODING

NOTES

ABDOMINAL AORTIC ANEURYSM, SCREENING

  • Males only (with any history of smoking)

  • Ages 65-75 years

  • One in a lifetime

76706 with diagnosis Z13.6, Z72.0, Z87.891, or F17.200-F17.219, F17.290-F17.299

 

ALCOHOL MISUSE SCREENING AND BEHAVIORAL COUNSELING INTERVENTIONS

  • One each calendar year (as needed)

G0442 and G0443 with diagnosis Z13.89, or F10.10, F10.11, F10.120, F10.129, F10.130, F10.139, Z13.39

10/1/22 add F10.90, F10.91

 

ASPIRIN FOR THE PREVENTION OF CARDIOVASCULAR DISEASE

For dates of service prior to April 1, 2023

  • Men ages 50-59 years
  • Women ages 13-59 years
  • Once every 5 calendar years

 

For dates of service prior to April 1, 2023

99401, 99386, 99387, 99396, or 99397, G0446 with diagnosis Z13.6 or Z76.89

 

 

For dates of service 4/1/23 and after, this service will no longer be considered under preventive. 

 

 

 

 

 

ASPIRIN USE TO PREVENT PREECLAMPSIA AND RELATED MORBIDITY AND MORTALITY: PREVENTIVE MEDICATION

For dates of service prior to April 1, 2023

  • Females age 10 years and older
To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy  

ASYMPTOMATIC BACTERIURIA IN PREGNANT WOMEN, SCREENING

87081, 87084, 87086, or 87088 with a routine prenatal or high risk prenatal diagnosis code

See end of document for a list of routine and high-risk prenatal diagnosis codes

BREAST AND OVARIAN CANCER SUSCEPTIBILITY, GENETIC RISK ASSESSMENT AND BRCA MUTATION TESTING

  • Females only
  • One session in a lifetime

Counseling:

96040 or 99401-99404 with diagnosis Z15.01, Z15.02, Z31.5, Z71.83, Z80.3, Z80.41, Z85.3 or Z85.43

Genetic Testing:

81163, 81164, 81165, 81166, 81167, 81212, 81215, 81216, and 81217 with diagnosis Z15.01, Z15.02, Z31.5, Z71.83, Z80.3, Z80.41, Z85.3 or Z85.43 OR 81162 and 81212 with diagnosis Z15.01, Z15.02, Z31.5, Z71.83, Z80.3, Z80.41, Z85.3 or Z85.43

Combined with chemo prevention of breast cancer

 

 

 

 

 

 

BREAST CANCER PREVENTION MEDICATION

  • Pharmacy only
  • Females only age 35 and older

To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy.

 

BREASTFEEDING, BEHAVIORAL INTERVENTIONS TO PROMOTE

  • Females only
  • Twice per calendar year

99401 must have modifier TH and diagnosis O09.00-O09.93, O09.A0-O09.A3, O36.80X0-O36.80X9, Z33.1, Z33.3, Z34.00-Z34.93 or Z39.1

 

CERVICAL CANCER, SCREENING (PAP SMEAR)

  • One each calendar year
  • No age limitations

88141, 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88155, 88164, 88165, 88166, 88167, 88174, 88175, G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001, or Q0091 with routine diagnosis

 

CHEMOPREVENTION OF BREAST CANCER

  • Females only
  • One in a lifetime

99401 or 99402 with diagnosis code Z80.3 or Z15.01

Combined with BRCA benefit above

CHLAMYDIA INFECTION, SCREENING

  • Females age 15-21
  • One each calendar year

 

 

 

  • Females age 22 years and older
  • One each calendar year

 

87110, 87270, 87320, 87490, 87491, 87492, or 87810 with routine diagnosis except Z11.3 (see STI Screening) OR 87800, 86631, 86632 with diagnosis Z11.8

 

 

 

87110, 87270, 87320, 87490, 87491, 87492, or 87810 with routine diagnosis OR 86631, 86632 with diagnosis Z11.8

10/24/22 remove code 87800

 

ROUTINE CHOLESTEROL (LIPID DISORDERS IN ADULTS), SCREENING

  • Men age 35 years and older (20-35 at risk for CAD)
  • Women age 45 years and older (20-45 at risk for CAD)
  • One every 5 calendar year

80061, 82465, 83718, 83721, 84478 with routine diagnosis

 

 

COLORECTAL CANCER, SCREENING

 

Pre-Screening Consultation

Effective 1/1/16

  • Once every 10 calendar years
  • Ages 50-75 years

Effective 5/18/21

  • Once every 10 calendar years
  • Ages 45-75 years

 

Colonoscopy

  • Once every 10 calendar years
  • Ages 50-75 years

Effective 5/18/21

  • Once every 10 calendar years
  • Ages 45-75 years

Includes outpatient facility services, physician services, and anesthesia.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bowel Prep Medications

Effective 7/1/16

  • Ages 50-75

Effective 5/18/21

  • Ages 45-75 years

 

 

 

 

 

 

 

 

 

 

Sigmoidoscopy

  • Ages 50-75 years
  • Once every 3 calendar years

Effective 5/18/21

  • Ages 45-75 years
  • Once every 3 calendar years

 

 

 

Barium Enema Part of standard COL

  • Ages 50-75 years
  • Once every 5 calendar years

Effective 5/18/21

  • Ages 45-75 years
  • Once every 5 calendar years

 

Fecal Occult Blood Testing (FOBT)

  • Ages 50-75 years
  • One each calendar year

Effective 5/18/21

  • Ages 45-75 years
  • One each calendar year

 

 

FIT-DNA (Cologuard™)

Effective 11/1/2017

  • Ages 50-75 years
  • Once every 3 calendar years

Effective 5/18/21

  • Ages 45-75 years
  • Once every 3 calendar years

 

CT Colonography (Visual Colonoscopy)

Effective 11/1/18

  • Ages 50-75 years
  • Once every 5 calendar years

Effective 5/18/21

  • Ages 45-75 years
  • Once every 5 calendar years

Same as COL rider

99386 or 99387 with diagnosis code Z12.11
Or

99396 or 99397 with diagnosis code Z12.11

Or

S0285 with diagnosis Z12.11

 

 

 

Colonoscopy (with routine diagnosis)

G0121, G0105, G6019, G6020, G6021, G6024, G6025, 44388, 44389, 44390, 44391, 44392, 44393, 44394, 44401, 44402, 44404, 44405, 44406, 44407, 45378, 45379, 45380, 45381, 45382, 45384, 45385, 45386, 45389, 45391, 45392 or 45399.

12/31/14 remove codes 44393, 44397, 45355, 45383, 45387

1/1/15 add codes 44401, 44402, 44404, 44405, 44406, 44407, 45388, 45389, G6019, G6020, G6024. G6025

1/1/16 remove codes G6019, G6020, G6021, G6024, G6025

 

Anesthesia

00810,99143-99145,99148-99150

With routine diagnosis

12/31/16 CANCEL 99143, 99144, 99145, 99148, 99149, 99150

1/1/17 ADD 99151, 99152, 99153, 99155, 99156, 99157, G0500

12/31/17 DELETE 00810

01/01/18 ADD 00812, 00811, 00813 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bowel Prep Medications

  • PEG-3350/NaCl/Na Bicarbon (NDC 10572030201)
  • PEG-3350/NaCl/Na Bicarbon (NDC 10572040001)
  • Gavilyte-N/Flavor Pack (NDC 43386005019)
  • Trilyte (NDC 51525683104)
  • PEG-3350/NaCl/Na Bicarbon (NDC 64380076921)

(GPIs: 46992004302120, 46992004302130, 46992004302140 (MSC=Y) only)

 

 

Sigmoidoscopy

G0104 or 45330 with routine diagnosis

 

1/1/16 add 45331, 45332, 45333, 45334, 45335, 45338, 45346, 45340, 45341, 45342, 45347


 

Barium Enema

G0106, G0120, G0122, or 74280 with routine diagnosis

 

 

 

 

 

Fecal Occult Blood Testing (FOBT)

G0107, G0328, G0394, 82270, 82272, or 82274 with routine diagnosis

 

 

 

 

 

FIT-DNA (Cologuard™)

81528 with routine diagnosis

 

 

 

 

 

 

CT Colonography (Visual Colonoscopy)

74263 with routine diagnosis

 

 

 

 

 

 

 

 

 

 

exams of biopsy(-ies) specimens (including polyps(s)) collected during a colonoscopy or sigmoidoscopy completed on the same date of service will also process without cost-sharing.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

USPSTF recommendation-Clinical Considerations–Patient Population under Consideration-These recommendations apply to adults 50 years of age and older, excluding those with specific inherited syndromes (the Lynch syndrome or familial adenomatous polyposis) and those with inflammatory bowel disease. The recommendations do apply to those with first-degree relatives who have had colorectal adenomas or cancer, although for those with first-degree relatives who developed cancer at a younger age or those with multiple affected first-degree relatives, an earlier start to screening may be reasonable. Furthermore, when the screening test results in the diagnosis of clinically significant colorectal adenomas or cancer, the patient will be followed by a surveillance regimen and recommendations for screening are no longer applicable.

CONGENITAL HYPOTHYROIDISM, SCREENING

  • Newborns-Ages 2-4 days

84436, 84437, 84439, or 84443 with diagnosis Z13.29

 

DENTAL CARIES IN CHILDREN FROM BIRTH THROUGH AGE 5 YEARS, PREVENTION OF

  • Birth–5 years

  • Male and Females

  • Maximum 4 per calendar year

CPT 99188 with Z29.3

 

 

 

DENTAL CARIES IN PRESCHOOL CHILDREN, PREVENTION

Included in preventive office visit

Per AAP’s Bright Futures Guidelines, this recommendation refers to the anticipatory guidance for oral health as an integral part of comprehensive patient counseling in the primary care setting.

DEPRESSION, ANXIETY, AND SUICIDE RISK SCREENING

  • Ages 11 years and older
  • One each calendar year

Effective 1/1/2023

  • Ages 11 years and older
  • Three each calendar year

Effective 11/1/2023

  • Ages 8 years and older
  • Three each calendar year

G0444, 96127 with diagnosis Z13.31 or Z13.32 1/1/2023 add Z13.39

 

 

DEVELOPMENTAL SCREENING

  • Ages 9-30 months
  • Five services during age range

G0451 or 96110 with a routine diagnosis code

 

DEVELOPMENTAL SURVEILLANCE FOR CHILDREN

Included as part of an office visit

 

DEVELOPMENTAL/BEHAVIORAL ASSESSMENT – ALCOHOL AND DRUG

  • Ages 11-21 years
  • One each calendar year

Effective 7/1/2021

  • Ages 11-21 years
  • One each calendar year with any diagnosis

G2011, G0396, G0442, G0443, or H0001 with diagnosis Z72.0, Z72.89, Z72.9, or Z73.9, Z13.89

 

7/01/2021 add 99408; removed Z72.0, Z72.89, Z72.9, or Z73.9, Z13.89. No specific diagnosis required

 

 

DYSLIPIDEMIA SCREENING

  • Ages 2-10 years: Once every 2 calendar years
  • Ages 11-17 years: One each calendar year
  • Ages 18-21 years: Once during age range

80061 with diagnosis Z13.220

 

DIET COUNSELING, BEHAVIORAL COUNSELING IN PRIMARY CARE TO PROMOTE A HEALTHY DIET 

  • Three hours each calendar year
  • Ages 19 and older

Effective 1/1/2021

  • Three hours each calendar year
  • Ages 18 and older

97802-97804, G0270, G0271, G0446, G0447 with diagnosis Z71.3, A18.84, E08.00-E13.9, E66.01-E66.1, E66.8, E66.9, I10-I22.9, I16.0, I16.1, I16.9, I21.9, I21.A1, I21.A9, I24.0-I25.9, I42.0-I43, I50.1-I50.9, I51.5-I51.7, I51.9, I52, N26.2, O24.011-O24.33, O24.811-O24.93, O99.210-O99.215, or Z68.30-Z68.45

1/13/2021 add E78.00, E78.01, E78.1, E78.2, E78.3, E78.41, E78.49, E78.5, E78.6, E88.81, R03.0

10/1/22 add I20.2, I25.112, I25.702, I25.712, I25.722, I25.732, I25.752, I25.762, I25.792

10/1/23 Remove E88.81. Add E88.810, E88.811, E88.818, E88.819, I20.81, I20.89, I21.B, I24.81, I24.89, I25.85   

 

GONORRHEA, SCREENING

  • Female only ages 22 years and older

(Ages 11-21 included in STI screening)

  • Two each calendar year

87590, 87591, 87850, 87800 or 87801 with diagnosis Z11.3

10/24/22 Remove 87800, 87801

 

GONORRHEA, PROPHYLACTIC MEDICATION, NEWBORN

No code available-usually administered as an ancillary charge while inpatient at time of delivery

 

HEALTHY WEIGHT AND WEIGHT GAIN IN PREGNANCY, COUNSELING

Effective 6/1/22

  • Ages 10 and older
  • Three hours each calendar year
99401-99404 with a routine prenatal diagnosis code, high risk prenatal diagnosis code   

HEMATOCRIT OR HEMOGLOBIN

  • Ages 4 months-10 years, no more than 3 tests.
  • Ages 11-21 years-one each calendar year

85013, 85014 or 85018 with diagnosis Z13.0

 

 

 

HEPATITIS B VIRUS INFECTION IN PREGNANCY, SCREENING FOR

  • Females (pregnant)
  • One each calendar year

87340 with diagnosis O09.00-O09.93, O36.80X0-O36.80X9, Z33.1, Z33.3, or Z34.00-Z34.93

 

 

 

 

HEPATITIS B VIRUS INFECTION IN NONPREGNANT ADOLESCENTS AND ADULTS, SCREENING FOR

  • Ages 11 years and older
  • Females and Males
  • One each CPT code per calendar year

Effective 1/1/2023

  • Ages newborn and older
  • One each CPT code per calendar year

G0499, 86704, 86705, 86706, 87340 or 87341 with diagnosis Z21, Z51.11, Z51.12, Z57.8, Z63.6, Z63.79, Z65.1, Z65.2, Z77.21, Z86.19, Z86.2, Z92.25, Z92.29, Z99.2, B17.10, B17.11, B18.2, B19.20 or B19.21

 

 

HEPATITIS C VIRUS (HCV) INFECTION, SCREENING

  • Once per lifetime screening for males and females
  • Once per year* screening for males and females at high risk for infection

 

Effective 4/1/2021

  • Once per lifetime screening for males and females
  • Once per year* screening for males and females at high risk for infection

86803, 86804, G0472 with:

  • Born 1945 through 1965 OR with dx code Z83.2 (being born to an HCV-infected mother) OR
  • For dx codes Z92.29, Z77.21, Z99.2, Z65.1, Z65.2, Z57.8

Effective 4/1/2021

  • 86803, 86804, G0472 – once per lifetime for males and females
  • 86803, 86804, G0472 – once per year for males and females at high risk for infection with diagnosis codes Z92.29, Z77.21, Z99.2, Z65.1, Z65.2, Z57.8, Z11.3, Z11.9, Z72.89, Z72.511, Z72.52, Z72.53, Z11.59, Z20.5, Z20.828, Z77.21

 

 

HIGH BLOOD PRESSURE, SCREENING

  • One each calendar year as needed.
  • Ages 18 years and older

Usually included as part of an office visit

 

 

 

 

 

 

 

 

HIGH BLOOD PRESSURE SCREENING (OUTSIDE OF THE CLINICAL SETTING)

Ambulatory Blood Pressure Monitoring:

  • One per lifetime to confirm the diagnosis of hypertension
  • Ages 18 years and older

 

Self-Measured Blood Pressure Monitoring:

  • One per lifetime to confirm the diagnosis of hypertension
  • Ages 18 years and older

Ambulatory Blood Pressure Monitoring:

93784 OR 93786, 93788, 93790 with diagnosis R03.0

 

Self-Measured Blood Pressure Monitoring:

99473-99474 with diagnosis R03.0

 

 

 

NOTE: Do not report ambulatory BP monitoring in the same calendar month as self-measure BP.

HIV SCREENING

  • Ages 11 years and older
  • No frequency

 

86701, 87535, 87534, 87389, 87390, 86703, 87806, G0432, G0433, G0435, G0475 with diagnosis Z11.4

 

HUMAN PAPILLOMAVIRUS (HPV) 

  • Ages 30 years and older (Females only)
  • One every 3 calendar years

0500T, G0476, 87623, 87624, or 87625 with routine diagnosis

Effective 9/1/2017, members will be allowed one additional service of 87625 as reflex testing if code 87624 result is documented as positive by the provider. This recommendation is response to guidelines published by The American College of Obstetricians and Gynecologists (ACOG), Number 168, October 2016

IMMUNIZATIONS

Routine Immunizations – Standard PMD Contracts

 

Routine Immunizations-Coverage is based on CDC’s Advisory Committee in Immunization Practices (ACIP) recommendations regarding age, frequency, and dosage.

Refer to the CDC website to view the schedules:

cdc.gov/vaccines/schedules/index.html

INPATIENT NEWBORN CARE

  • Newborns

Inpatient physician services only

 

99221-99223, 99231-99233, 99234-99236, 99238, 99239, 99460, 99462-99464, 99478-99480 with a routine diagnosis

 

IRON DEFICIENCY ANEMIA, PREVENTION

Pharmacy Benefit

 

IRON DEFICIENCY ANEMIA, SCREENING

  • Females (pregnant)
  • One each calendar year

85013, 85014, 85018, 85025, OR 85027 with diagnosis O09.00-O09.93, O36.80X0-O36.80X9, Z33.1, Z33.3, OR Z34.00-Z34.93

 

LEAD SCREENING

  • Ages 6 months – 6 years
  • 3 tests during age range

83655 with diagnosis Z13.88

 

LUNG CANCER, SCREENING WITH LOW-DOSE COMPUTED TOMOGRAPHY

  • 55-80 years old
  • Male and Females
  • One each calendar year

Effective 3/22/2021

  • 50-80 years old
  • Male and Females
  • One each calendar year

71271 with Z12.2 AND Z87.891, F17.210, F17.211, F17.213, F17.218 OR F17.219

 

MAMMOGRAPHY (BREAST CANCER SCREENING)

  • One baseline for females ages 35-39 years
  • One annually for females age 40 and over
 77063, 77065, 77066, or 77067 with routine diagnosis
NOTE: When submitted with a preventive/routine code AND in conjunction with the screening mammography code, 77063 should process per HCP with no cost sharing.

MATERNAL DEPRESSION SCREENING

  • Ages birth-6 months
  • 4 services during age range

96161 with routine diagnosis

 

 

NEWBORN METABOLIC/HEMOGLOBIN SCREENING

  • Ages 0-2 months
  • One test during age range

S3620 with no specific diagnosis required

 

NEWBORN SCREENING PANEL

  • Ages birth-31 days

83498 or 83788 with Z13.21, Z13.228, Z13.29

83020 with Z13.0

82261 with Z13.21, Z13.228, Z13.29

83516 with Z13.228

82776 with Z13.228

86355 or 86359 with Z13.21, Z13.228, Z13.29

82760 with Z13.228

82759 with Z13.228

86359 with Z13.21, Z13.228, Z13.29

83789 with Z13.228

 

OBESITY IN ADULTS AND CHILDREN SCREENING

  • Ages 6 years and older
  • One per calendar year

99401, G0447 with diagnosis Z13.89, Z68.53, Z68.54

 

ORAL HEALTH

  • Ages 6 months-6 years
  • 3 services during age range

96160 with Z13.84

 

OSTEOPOROSIS IN POSTMENOPAUSAL WOMEN SCREENING

  • Ages 65 and older. 65 and younger if at risk
  • Females only
  • Once every 2 calendar years

77080 with diagnosis E05.00-E05.91, E10.10-E10.9, E23.6, E28.310- E28.39 E44.0-E46, E64.0, E89.40, E89.41, F10.20-F10.220, F10.229, F17.200-F17.299, K70.0-K70.40, K70.9, K73.0-K74.69, K75.4, K75.81, K76.0, K76.89, K76.9, K90.0-K90.49, K90.89, K90.9, K91.2, M05.00-M06.9, M08.00- M08.9A, M12.00-M12.09, M45.0-M45.9, M48.8X1-M48.8X9, Q78.0, Q96.0-Q96.9, Z13.820, Z71.41, Z72.0, Z82.62, Z86.39, Z87.310-Z87.312, Z87.81, Z90.721- Z90.79, or Z92.241

10/1/21 added M45.A0, M45.A1, M45.A2, M45.A3, M45.A4, M45.A5, M45.A6, M45.A7, M45.A8, M45.AB

 

 

 

 

 

 

 

ASPIRIN (OVER–THE–COUNTER)

For dates of service 4/1/23 and after, this service will no longer be considered under preventive. 

  • Men aged 50-59 years
  • Women aged 13 – 59 years
To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy. For dates of service 4/1/23 and after, this service will no longer be considered under preventive. 

CONTRACEPTIVE METHODS

  • Women only
  • Generic only
To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy.  

FLUORIDE (OVER–THE–COUNTER)

  • Ages 6 months – 16 years
To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy.  

FOLIC ACID (OVER–THE–COUNTER)

  • Women only
To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy.  

IRON SUPPLEMENTS (OVER–THE–COUNTER)

  • Ages 6 months to 12 months
To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy.  

PHENYLKETONURIA SCREENING (PKU)

  • Ages 2-14 days
  • Two tests during age range

84030 with diagnosis Z13.228

 

 

 

 

PROSTATE SPECIFIC ANTIGEN (PSA)

  • Ages 40 years and over
  • Annually

G0103 or 84153 with routine diagnosis

 

 

RH (D) INCOMPATIBILITY, SCREENING

  • Two per calendar year
  • Females only

86901 with diagnosis O09.00-O09.93, O36.80X0-O36.80X9, Z33.1, Z33.3, or Z34.00-Z34.93

 

PREECLAMPSIA SCREENING

  • Females only beginning at age 10

Included in prenatal office visit

 

Prenatal Conference

  • with Pediatricians only

CPT codes 99202-99203 or 99211-99213 with diagnosis Z76.81

 

PREVENTION OF FALLS

  • Age 65 years and older

97110, 97112, 97116, G0151, or G0159 with diagnosis Z91.81, limited to 40 services each calendar year (= 10 hours of physical therapy)

OR

97150 with diagnosis Z91.81, limited to 10 services each calendar year

OR

S9131 with diagnosis Z91.81, limited to 10 services each calendar year

 

PREVENTION OF HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTION: PRE-EXPOSURE

To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy.

Effective 9/17/2021
The following services for baseline/follow-up testing and monitoring are included per the CDC PrEP guidelines with diagnosis codes, Z11.3, Z11.4, Z20.2, Z20.6, Z51.81, Z72.51, Z72.52, Z72.53, Z72.89, Z77.21, OR Z79.899:

  • Kidney function testing (creatinine): 82565, 82575
  • Hepatitis B testing: G0499, 86704, 86705, 86706, 87340 or 87341
  • Hepatitis C testing: 86803, 86804, G0472
  • HIV: 86701, 87535, 87534, 87390, 86703, 87389, 87806, G0432, G0433, G0435 or G0475
  • STI Testing: 86592, 86780, 87590, 87591, 87850, 87800, 87801, 86631, 86632, 86701, 86703, 87081, 87110, 87205, 87210, 87270, 87320, 87490, 87491, 87590, 87591, 87800, 87810, 87850, 87563
  • Preventive Medicine Counseling: 99401, 99402
  • Pregnancy testing (when appropriate): 81025, 84702, 84703
  • E/M Office Visits


12/20/21 Physician-administered pre-exposure prophylaxis- Apretude (cabotegravir) J3490 with NDC 49702-0264-23 (ages 12 and older) with Z11.3, Z11.4, Z20.2, Z20.6, Z51.81, Z72.51, Z72.52, Z52.53, Z72.89, Z77.21, Z79.899

7/1/22 Removed J3490. Add J0739

10/24/22 Removed 87800, 87801

5/22/23 Removed Z51.81 and Z79.899 from E/M Office Visits

10/1/23 Add Z29.81 

1/1/24 Add G0011, G0012, G0013

 

PREVENTIVE HISTORY AND PHYSICAL EXAMINATIONS

  • 9 visits the first 2 years of life
  • Age 2 years -two per birth year
  • Ages 3-6 years -one each year (based on birth year)
  • Ages 7 years and older- Males one each calendar year
  • Ages 7- 9 years- Females one each calendar year
  • Ages 10 years and older -Females one each calendar year (excludes the Well Women’s Preventive Examinations procedure/diagnosis code combinations)

G0101, G0102, G0438, G0439, G0463, G0513, G0514, S0612, S0613, 99202 - 99215, 99241 - 99245, 99381 - 99387, 99391 - 99397

 

PSYCHOSOCIAL/BEHAVIORAL ASSESSMENT

  • Newborn – 21 years
  • 31 services during age range

96127 with routine diagnosis

HEARING, SENSORY SCREENING 

  • Ages 2 months-10 years – no more than eight tests
  • Ages 11-21 years – no more than three tests

92551, 92552, 92558, 92567, 92587, 92650, 92651 or V5008 with diagnosis Z00.121, Z00.129, Z01.10, Z01.118 or Z13.5

 

HEARING, NEWBORN SCREENING 

  • Newborn-31 days 
  • One in a lifetime

92558, 92587, 92650, 92651 with diagnosis Z00.110, Z00.111, Z00.121, Z00.129, Z01.10, Z01.118, Z13.5

 

 

SEXUALLY TRANSMITTED INFECTIONS, BEHAVIORAL COUNSELING INTERVENTIONS TO PREVENT

  • Ages 10 years and older once each calendar year

 

99401, 99402, G0445 with diagnosis Z71.89, Z72.51, Z72.52 OR Z72.53 OR 99403, 99404, G0445 with diagnosis Z71.7, Z71.89, Z72.51, Z72.52, OR Z72.53

 

 

 

SEXUALLY TRANSMITTED INFECTIONS (STI), SCREENING

  • Ages 11-21 years
  • No frequency

86631, 86632, 86701, 86703, 87081, 87110, 87205, 87210, 87270, 87320, 87490, 87491, 87563, 87590, 87591, 87810, or 87850 with diagnosis Z11.3

10/24/2022 remove code 87800

 

SICKLE CELL DISEASE SCREENING

  • Age 0-31 days
  • No frequency

83020 or 83021 with diagnosis Z13.0

 

SKIN CANCER, BEHAVIORAL COUNSELING TO PREVENT

  • Ages 6 months-24 years

Included in E&M and/or preventive office visits

 

STATIN USE FOR THE PRIMARY PREVENTION OF CARDIOVASCULAR DISEASE IN ADULTS

  • Ages 40-75 years
  • No history of cardiovascular disease (CVD)
  • One or more risk factors
  • Calculated 10-year CVD event risk of 10% or greater

 

To be considered under the Pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy

Generic Pravastatin and Lovastatin are included products

SYPHILIS INFECTION SCREENING

  • No frequency

86592 or 86780 with diagnosis Z11.3

 

 

SUDDEN CARDIAC ARREST AND SUDDEN CARDIAC DEATH SCREENING

Effective 1/1/23

  • Ages 11-21 years
Included in E&M and/or preventive office visits  

TOBACCO USE AND TOBACCO-CAUSED DISEASE COUNSELING

  • 8 total per calendar year
  • Ages 6 years and older

Pregnant Females

  • 8 total per calendar year
  • Ages 10 years and older

99406, 99407 diagnosis F17.200-F17.299, or Z72.0

Pregnant Females

99406 or 99407 with diagnosis O99.330-O99.333

 

TOBACCO USE AND TOBACCO-CAUSED DISEASE, MEDICATION

  • Two 90 day supplies

 

To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy.

All Food and Drug Administration (FDA)-approved tobacco cessation medications (including both prescription and over-the-counter medications) for a 90-day treatment regimen when prescribed by a health care provider without prior authorization.

TYPE 2 DIABETES MELLITUS IN ADULTS, SCREENING

  • Males Ages 19 years and older
  • Females Ages 10 years and older
  • Once every 3 years

82947 OR 83036 with diagnosis Z13.1, Z86.32

 

TUBERCULIN TEST

  • Ages 1 month-21 years
  • 6 tests during age range

86580 with diagnosis Z11.1

 

TUBERCULOSIS INFECTION, LATENT, IN ADULTS, SCREENING FOR

  • Adults at risk, ages 19 years and older

  • Once per year allowed if at risk or continued risk

86580, 86480, OR 86481 with diagnosis Z11.1, Z11.7

 

 

 

UNHEALTHY DRUG USE SCREENING (ADULTS)

  • Ages 18 years and older
  • Once each calendar year 
G0396, G2011, H0001 or 99408  

URINARY INCONTINENCE, SCREENING

  • Females Ages 10 years and older

Included in E&M and/or Preventive office visits

 

VISUAL ACUITY SCREENING IN CHILDREN

  • Newborn – age 10 – limited to 8 tests in age range
  • Ages 11-21 years – limited to 4 tests during age range

99173, 99174, 99177 with diagnosis Z00.110, Z00.111, Z01.00, Z00.129, Z00.121, Z01.01 or Z13.5

 

 

WOMEN’S PREVENTIVE SCREENINGS

DESCRIPTION

CODING

NOTES

WELL WOMAN PREVENTIVE OFFICE VISITS

  • Females only beginning at age 10

 

CPT codes 99383-99387, G0438, or S0610 with diagnosis Z00.00 or Z00.01 – limited to 1 per calendar year

CPT codes 99383-99387, G0438, or S0610 with diagnosis Z01.411 or Z01.419 – limited to 1 per calendar year

CPT codes 99393-99397, G0439, 
S0612, or S0613 with diagnosis Z00.00, Z00.01, Z01.411, or Z01.419 – limited to 2 per calendar year  
 

 

PERINATAL DEPRESSION PREVENTIVE INTERVENTIONS

  • Ages 10 and older
  • Females only
  • Three hours each calendar year
99401-99404 with a routine prenatal diagnosis code, high risk prenatal diagnosis code OR Z39.2  

PRECONCEPTION

  • Females only beginning at age 10
  • One visit per calendar year

99383-99387, G0438, or S0610 with Z31.69 or Z31.7

 

PRENATAL CARE

  • Females only beginning at age 10

 

99202-99215 with routine prenatal diagnosis, limited to 3 visits each calendar year

99202-99215 with high risk prenatal diagnosis

59425 regardless of diagnosis, limited to 2 visits each calendar year

59426 regardless of diagnosis, limited to 1 visit each calendar year

Codes for prenatal visits should be filed separate from global maternity to ensure member coverage at 100% with no cost share.

See end of document for a list of routine and high-risk prenatal diagnosis codes.

SCREENING FOR DIABETES AFTER PREGNANCY

Effective 1/1/24

  • Females only beginning at age 10
  • Limit two per calendar year
82947, 83036, 82951, or 82952 with Z86.32  

SCREENING FOR DIABETES DURING PREGNANCY

  • Females only beginning at age 10
  • Limit two per calendar year

 

82947, 83036, 82951, or 82952 with a routine prenatal or high risk prenatal diagnosis

 

See end of document for a list of routine and high-risk prenatal diagnosis codes.

HIV COUNSELING

  • Females only beginning at age 10
  • Annually

99401 or 99402 with diagnosis Z71.7

 

CONTRACEPTIVE METHODS AND COUNSELING

  • Female only beginning at age 10
  • Annually
99401 with diagnosis codes Z30.011- Z30.09, Z30.40-Z30.42, Z30.431, Z30.49, Z30.9, Z30.44, Z30.45, or Z30.46  

STERILIZATION

  • Female only
  • One procedure per lifetime
58600, 58661, 58605, 58611, 58615, 58670, 58671, 58700, 00851 with diagnosis code Z30.2 Note: Effective 12/31/18, Essure (58565/ A4264) no longer available in the US.

MEDICAL CONTRACEPTIVE METHODS

 

A4261, A4266, 11976, 11981, 11982, 11983, 57170, 58300, 58301, J1050, J7296, J7297, J7298, J7300, J7301, J7303, J7304, J7306, J7307, S4981, S4989, with diagnosis codes Z30.013- Z30.019, Z30.09, Z30.40, Z30.42, Z30.430, Z30.431, Z30.432, Z30.433, Z30.44, Z30.45, Z30.46, Z30.49, Z30.9

9/30/2021 remove J7303

10/1/2021 add J7294, J7295

1/1/24 Add 96372 (for Depo-Provera administration)

Note: (For dates of services prior to 1/1/24) Injection code 96372 if Depo-Provera was given was not added to HCR Women’s Preventive Coding since we are unable to tie it back to a matching procedure to provide accurate coverage

PHARMACY CONTRACEPTIVE METHODS

  • Generic only
To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled by the pharmacy Brand coverage may be available, contact Customer Service for additional information

BREASTFEEDING – COUNSELING AND SUPPORT

  • Three per year in conjunction with birth

Effective 1/1/2023

  • Five per year in conjunction with birth
99402-99404 with modifier TH and diagnosis code Z39.1  

BREASTFEEDING – SUPPLIES

(Pumps and Accessories)

 

Pumps – E0602, E0603 with type service H for rental or G for purchase, E0604 (rental only)

Accessories – A4281, A4282, A4283, A4284, A4285, A4286

1/1/2023 add code K1005

12/31/2023 Delete code K1005

1/1/2024 Add code A4287

E0603 – one pump allowed per pregnancy

The requirement to cover the rental or purchase of breastfeeding equipment without cost sharing extends for the duration of breastfeeding, provided the individual remains continuously enrolled in the plan or coverage.

SCREENING AND COUNSELING FOR INTERPERSONAL AND DOMESTIC VIOLENCE

  • Females only beginning at age 10
  • Annually

99401-99404 with diagnosis codes Z69.010-Z69.12, Z69.82

 

SCREENING FOR INTIMATE PARTNER VIOLENCE AND ABUSE OF ELDERLY AND VULNERABLE ADULTS

  • Females only beginning at age 10
  • Annually
99401-99404 with diagnosis codes Z65.9, Z69.010-Z69.12, Z69.82, Z71.89  

PREVENTING OBESITY IN MIDLIFE WOMEN

Effective 1/1/2023

  • Women ages 40-60 years
  • 1 hour per year (any combination of 99401- 99404)
99401, 99402, 99403, 99404 with diagnosis Z68.1, Z68.20, Z68.21, Z68.22, Z68.23, Z68.24, Z68.25, Z68.26, Z68.27, Z68.28, Z68.29  

 

ROUTINE PRENATAL DIAGNOSIS CODES O21.0, O22.00-O22.13, O22.40-O22.43, O22.8X1-O22.8X9, O42.10-O42.119, O47.00-O48.0, O92.011-O92.019, O92.111-O92.119, O92.20-O92.3, O92.5-O92.79, Z03.71-Z03.79, Z32.01, Z33.1, Z33.3, Z34.00-Z36.5, Z36.81-Z36.89, Z64.0
HIGH RISK PRENATAL DIAGNOSIS CODES 

O00-O07.4, O09.00-O10.019, O10.111-O10.119, O10.211-O10.219, O10.311-O10.319, O10.411-O10.419, O10.911-O10.919, O11.1-O15.03, O15.9-O20.9, O21.1- O21.9, O22.20-O22.33, O22.50-O22.53, O22.90-O24.019, O24.111-O24.119, O24.311-O24.319, O24.410-O24.419, O24.811-O24.819, O24.911-O24.919, O25.10- O25.13, O26.00-O26.43, O26.611-O26.619, O26.711-O26.719, O26.811-O26.93, O29.011-O30.93, O31.00X-O32.9XX (7th character 0,1,2,3,4,5, or 9), O33.0- O33.2, O33.3XX-O33.6XX (7th character 0,1,2,3,4,5, or 9), O33.7XX0-O34.93, O35.0XX-O41.93X (7th Character 0,1,2,3,4,5, or 9), O42.00-O42.019, O42.90- O42.919, O43.011-O46.93, O48.1-O60.03, O60.10X (7th character 0,1,2,3,4,5, or 9), O60.20X (7th character 0,1,2,3,4,5,or 9), O91.011-O91.019, O91.111-O91.119, O91.211-O91.219, O91.23, O98.011-O98.019, O98.111-O98.119, O98.211-O98.219, O98.311-O98.319, O98.411-O98.419, O98.511-O98.519, O98.611-O98.619, O98.711-O98.719, O98.811-O98.819, O98.911-O98.919, O99.011-O99.019, O99.111-O99.119, O99.210-O99.213, O99.280-O99.283, O99.310-O99.313, O99.320-O99.323, O99.330-O99.333, O99.340-O99.343, O99.350-O99.353, O99.411-O99.419, O99.511-O99.519, O99.611-O99.619, O99.711-O99.719, O99.810, O99.820, O99.830, O99.840-O99.843, O99.89, O9A.111-O9A.119, O9A.211-O9A.219, O9A.311-O9A.319, O9A.411-O9A.419, O9A.511-O9A.519, Z33.2

10/1/22 add O35.00X0, O35.00X1, O35.00X2, O35.00X3, O35.00X4, O35.00X5, O35.00X9, O35.01X0, O35.01X1, O35.01X2, O35.01X3, O35.01X4, O35.01X5, O35.01X9, O35.02X0, O35.02X1, O35.02X2, O35.02X3, O35.02X4, O35.02X5, O35.02X9, O35.03X0, O35.03X1, O35.03X2, O35.03X3, O35.03X4, O35.03X5, O35.03X9, O35.04X0, O35.04X1, O35.04X2, O35.04X3, O35.04X4, O35.04X5, O35.04X9, O35.05X0, O35.05X1, O35.05X2, O35.05X3, O35.05X4, O35.05X5, O35.05X9, O35.06X0, O35.06X1, O35.06X2, O35.06X3, O35.06X4, O35.06X5, O35.06X9, O35.07X0, O35.07X1, O35.07X2, O35.07X3, O35.07X4, O35.07X5, O35.07X9, O35.08X0, O35.08X1, O35.08X2, O35.08X3, O35.08X4, O35.08X5, O35.08X9, O35.09X0, O35.09X1, O35.09X2, O35.09X3, O35.09X4, O35.09X5, O35.09X9, O35.10X0, O35.10X1, O35.10X2, O35.10X3, O35.10X4, O35.10X5, O35.10X9, O35.11X0, O35.11X1, O35.11X2, O35.11X3, O35.11X4, O35.11X5, O35.11X9, O35.12X0, O35.12X1, O35.12X2, O35.12X3, O35.12X4, O35.12X5, O35.12X9, O35.13X0, O35.13X1, O35.13X2, O35.13X3, O35.13X4, O35.13X5, O35.13X9, O35.14X0, O35.14X1, O35.14X2, O35.14X3, O35.14X4, O35.14X5, O35.14X9, O35.15X0, O35.15X1, O35.15X2, O35.15X3, O35.15X4, O35.15X5, O35.15X9, O35.19X0, O35.19X1, O35.19X2, O35.19X3, O35.19X4, O35.19X5, O35.19X9, O35. AXX0, O35.AXX1, O35.AXX2, O35.AXX3, O35.AXX4, O35.AXX5, O35.AXX9, O35.BXX0, O35.BXX1, O35.BXX2, O35.BXX3, O35.BXX4, O35.BXX5, O35.BXX9, O35.CXX0, O35.CXX1, O35.CXX2, O35.CXX3, O35.CXX4, O35.CXX5, O35.CXX9, O35.DXX0, O35.DXX1, O35.DXX2, O35.DXX3, O35.DXX4, O35.DXX5, O35.DXX9, O35.EXX0, O35.EXX1, O35.EXX2, O35. EXX3, O35.EXX4, O35.EXX5, O35.EXX9, O35.FXX0, O35.FXX1, O35.FXX2, O35.FXX3, O35.FXX4, O35.FXX5, O35.FXX9, O35.GXX0, O35.GXX1, O35.GXX2, O35.GXX3, O35.GXX4, O35.GXX5, O35.GXX9, O35.HXX0, O35.HXX1, O35.HXX2, O35.HXX3, O35.HXX4, O35.HXX5, O35.HXX9 10/1/22 remove O350XX0, O350XX1, O350XX2, O350XX3, O350XX4, O350XX5, O350XX9, O351XX0, O351XX1, O351XX2, O351XX3, O351XX4, O351XX5, O351XX9

10/1/23 Add O26.641, O26.642, O26.643, O26.649

 

 

The Patient Protection and Affordable Care Act (ACA) defines preventive care services as follows:

  • Items or services recommended with an A or B rating by the U.S. Preventive Services Task Force.

  • Immunization recommended by the Advisory Committee on Immunization Practices (ACIP) of the Center for Disease Control (CDC). (children , adolescent, and adult)

  • Preventive care and screening for infants, children, and adolescents supported by the Health Resources and Services Administration (Bright Futures).

  • Preventive care and screening for women supported by the Health Resources and Service Administration. (These guidelines have not been defined yet.)

 

All providers must use the codes provided in this document when filing claims for healthcare reform mandated preventive services for a Blue Plan member.

 

If the preventive services section of your plan's benefit booklet refers to any of the preventive services and immunizations in this document, they will be covered by your health plan. However, a group may decide to delay the effective date for coverage until the group's plan year for any new preventive services and immunizations recently added to this list. If a plan covers these services, please be aware that in some cases, routine preventive services and routine immunizations may be billed separately from an office or other facility visit. In that case, the applicable office visit or outpatient facility copayments described in the physician benefits and outpatient hospital benefits sections of the benefit booklet may apply. In any case, applicable office visit or facility copayments may still apply when the primary purpose for a visit is not routine preventive services and/or routine immunizations. If you have any questions about a plan’s benefits, you may call our Customer Service Department at the number on the back of the ID card.

Revised 12/23 LR