Preventive Services
Preventive Services Due to the Patient Protection and Affordable Care Act (commonly referred to as federal health care reform), with the exception of groups maintaining "grandfathered" status, all Tufts Health Plan plans are required to provide 100% coverage for preventive care services. Grandfathered groups are not subject to this requirement, but many of these groups have opted to cover preventive services with no cost sharing. This means that members will have no cost-sharing responsibility when preventive services are rendered by an innetwork provider. Members may still be required to pay a copayment, deductible or coinsurance for preventive services received from out-of-network providers (PPO and POS plans), or for non-preventive services received in conjunction with a preventive services visit. Preventive services identified in this policy are based on recommendations from the U.S. Preventive Services Task Force, Bright Futures, American Academy of Pediatrics (AAP), Centers for Disease Control and Prevention (CDC) and Advisory Committee for Immunization Practices (ACIP). Tufts Health Plan accepts and recognizes the use of modifier 33 when billed with services on the U.S. Preventive Services Task Force List that have an A or B rating. The American Medical Association created this modifier to allow providers to identify a preventive service for which patient cost sharing does not apply under the Patient Protection and Affordable Care Act, which prohibits patient cost sharing for non-grandfathered plans. Modifier 33 is appropriate to use with a CPT code that is a diagnostic/treatment service being performed as a preventive service. Refer to the Modifier Payment Policy for more information regarding modifiers. Tufts Health Plan covers the women’s preventive health care services as indicated in the Woman’s Health section of this document, with no cost share for most members when those services are rendered by a provider in the member’s plan network. Please refer to the Woman’s Health section of this document for additional information. Providers and their office staff are required to use self-service channels to verify effective dates and copayments for commercial members prior to initiating services. VENIPUNCTURE The below CPT code is considered preventive when billed with Modifier 33 and/or when billed with one of the below ICD-9 or ICD-10 codes: CPT Code Description 36415 Collection of venous blood by venipuncture ICD-9 Diagnosis Code V20.2 V20.31 V20.32 V22.0 V22.1 V22.2 V23.0 V23.1 V23.2 V23.3 V23.41 V23.49 V23.5 V23.7 V23.81 V23.82 V23.83 V23.84 V23.85 Revised 06/09/14 2163789 Description Routine infant or child health check Health supervision for newborn under 8 days old Health supervision for newborn 8 to 28 days old Supervision of normal pregnancy Supervision of other than normal pregnancy Pregnant state, incidental Pregnancy with history of infertility Pregnancy with history of trophoblastic disease Pregnancy with history of abortion Grand multiparity Pregnancy with history of labor pre-term Pregnancy with other poor obstetric history Pregnancy with other poor reproductive history Insufficient prenatal care Elderly primigravida Elderly multigravida Young primigravida Young multigravida Pregnancy resulting from assisted reproductive technology 1 Preventive Services ICD-9 Diagnosis Code V23.86 V23.89 V23.9 V25.2 V70.0 V72.62 V77.1 V77.91 Description Pregnancy with history of in-utero procedure during previous pregnancy Other high-risk pregnancy Unspecified high-risk pregnancy Sterilization Routine general medical examination at a health care facility Laboratory examination ordered as part of a routine general medical examination Diabetes mellitus Screening for lipid disorders The following ICD-10 codes are effective for dates of service on or after October 1, 2015: ICD-9 Diagnosis Code Description O09.00 - O09.93 Supervision of high risk pregnancy Z00.00 Encounter for general adult medical examination without abnormal findings Z00.110 Health examination for newborn under 8 days old Z00.111 Health examination for newborn 8 to 28 days old Z00.129 Encounter for routine child health examination without abnormal findings Z13.1 Encounter for screening for diabetes mellitus Z13.220 Encounter for screening for lipoid disorders Z30.2 Encounter for sterilization Z33.1 Pregnant state, incidental Z34.00 - Z34.93 Encounter for supervision of normal pregnancy PREVENTIVE OFFICE VISITS The below CPT codes are considered preventive: CPT Code Description Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction 99381 interventions, and the ordering of laboratory/diagnostic procedures, new patient; infant (age younger than 1 year) Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction 99382 interventions, and the ordering of laboratory/diagnostic procedures, new patient; early childhood (age 1 through 4 years) Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction 99383 interventions, and the ordering of laboratory/diagnostic procedures, new patient; late childhood (age 5 through 11 years) Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction 99384 interventions, and the ordering of laboratory/diagnostic procedures, new patient; adolescent (age 12 through 17 years) Initial comprehensive preventive medicine evaluation and management of an individual including an age 99385 and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 18-39 years Initial comprehensive preventive medicine evaluation and management of an individual including an age 99386 and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 40-64 years Initial comprehensive preventive medicine evaluation and management of an individual including an age 99387 and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 65 years and older Revised 06/09/14 2 Preventive Services CPT Code 99391 99392 99393 99394 99395 99396 99397 99460 99461 99462 99463 G0438 G0439 Description Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; infant (age younger than 1 year) Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; early childhood (age 1 through 4 years) Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; late childhood (age 5 through 11 years) Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 years) Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18-39 years Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and older Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant Initial care, per day , for evaluation and management of normal newborn infant seen in other than hospital or birthing center Subsequent hospital care, per day, for evaluation and management of normal newborn Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant admitted and discharged on the same date Annual wellness visit; includes a personalized prevention plan of service (PPS), initial visit Annual wellness visit, includes a personalized prevention plan of service (PPS), subsequent visit ROUTINE HEALTH SCREENINGS: ADULT Abdominal Aortic Aneurysm: Men ages 65-75 The below CPT/HCPCS codes are considered preventive when billed with one of the following - ICD-9 codes V15.82 (Personal history of tobacco use, presenting hazards to health), V81.2 (Screening for other and unspecified cardiovascular conditions) or ICD-10 codes Z13.6 (Encounter for screening for cardiovascular disorders), Z87.891 (Personal history of nicotine dependence): CPT/HCPCS Code Description 76700 Ultrasound, abdominal, real time with image documentation; complete Ultrasound, abdominal, real time with image documentation; limited (e.g., single organ, quadrant, 76705 follow-up) Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), real time with image documentation; 76770 complete 76775 Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), real time with image documentation; limited Ultrasound B-scan and/or real time with image documentation; for abdominal aortic aneurysm G0389 (AAA) screening Revised 06/09/14 3 Preventive Services Asymptomatic Bacteriuria, Rh (D) Blood Typing (first pregnancy related visit), Iron Deficiency Anemia Pregnant Women CPT codes 81000 (Urinalysis), 86901 (Blood typing; Rh (D)), 85025 (Blood count; complete) and 85027 (Blood count; complete) are considered preventive when billed with one of the below ICD-9 or ICD-10 diagnosis codes: ICD-9 Diagnosis Code Description V22.0 Supervision of normal pregnancy V22.1 Supervision of other than normal pregnancy V22.2 Pregnant state, incidental V23.0 Pregnancy with history of infertility V23.1 Pregnancy with history of trophoblastic disease V23.2 Pregnancy with history of abortion V23.3 Grand multiparity V23.41 Pregnancy with history of labor pre-term V23.49 Pregnancy with other poor obstetric history V23.5 Pregnancy with other poor reproductive history V23.7 Insufficient prenatal care V23.81 Elderly primigravida V23.82 Elderly multigravida V23.83 Young primigravida V23.84 Young multigravida V23.85 Pregnancy resulting from assisted reproductive technology V23.86 Pregnancy with history of in-utero procedure during previous pregnancy V23.89 Other high-risk pregnancy V23.9 Unspecified high-risk pregnancy The following ICD-10 codes are effective for dates of service on or after October 1, 2015: ICD-10 Diagnosis Code Description O09.00 - O09.93 Supervision of high risk pregnancy Z33.1 Pregnant state, incidental Z34.00 - Z34.93 Encounter for supervision of normal pregnancy Blood Pressure Screening: Adults ages 18 and older Included in preventive evaluation and management visit BRCA Genetic Testing* The below CPT/HCPCS codes are considered preventive when billed with one of the following - ICD-9 codes V16.3 (Family history of malignant neoplasm, breast) or V16.41 (Family history of malignant neoplasm, genital organs, ovary) or ICD-10 codes Z80.3 (Family history of malignant neoplasm of breast) or Z80.41 (Family history of malignant neoplasm of ovary): CPT/HCPCS Code Description BRCA1, BRCA2 (breast cancer 1 and 2) (e.g., hereditary breast and ovarian cancer) gene analysis; full 81211 sequence analysis and common duplication/deletion variants in BRCA1 BRCA1, BRCA2 (breast cancer 1 and 2) (e.g., hereditary breast and ovarian cancer) gene analysis; 81212 185delAG, 5385insC, 6174delT variants BRCA1, BRCA2 (breast cancer 1 and 2) (e.g., hereditary breast and ovarian cancer) gene analysis; 81213 uncommon duplication/deletion variants BRCA1 (breast cancer 1) (e.g., hereditary breast and ovarian cancer) gene analysis; full sequence 81214 analysis and common duplication/deletion variants BRCA1 (breast cancer 1) (e.g., hereditary breast and ovarian cancer) gene analysis; known familial 81215 variant BRCA2 (breast cancer 2) (e.g., hereditary breast and ovarian cancer) gene analysis; full sequence 81216 analysis BRCA2 (breast cancer 2) (e.g., hereditary breast and ovarian cancer) gene analysis; known familial 81217 variant Revised 06/09/14 4 Preventive Services *Prior Authorization is required for BRCA Genetic Testing. Please refer to our Medical Necessity Guidelines. Breast Cancer: Screening with Mammography ages 40 and older The below CPT/HCPCS codes are considered preventive: CPT/HCPCS Code Description Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) 77052 with further physician review for interpretation, with or without digitization of film radiographic images 77057 Screening mammography, bilateral (2-view film study of each breast) G0202 Screening mammography, producing direct digital image, bilateral, all views Cervical Cancer The below CPT/HCPCS codes are considered preventive when billed with one of the following - ICD-9 code V76.2 (Screening for malignant neoplasm of the cervix) or ICD-10 code Z12.4 (Encounter for screening for malignant neoplasm of cervix): CPT/HCPCS Code Description 88141 Cytopathology, cervical or vaginal (any reporting system), requiring interpretation by physician Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated 88142 thin layer preparation; manual screening under physician supervision 88143 Cytopathology, cervical or vaginal (any reporting system) 88147 Cytopathology smears, cervical or vaginal; screening by automated system 88148 Cytopathology smears, cervical or vaginal; screening by automated system with manual rescreening 88150 Cytopathology, slides, cervical or vaginal; manual screening 88152 Cytopathology, slides, cervical or vaginal; with manual screening and computer-assisted rescreening 88153 Cytopathology, slides, cervical or vaginal; with manual screening and rescreening Cytopathology, slides, cervical or vaginal; with manual screening and computer-assisted rescreening 88154 using cell selection and review 88155 Cytopathology, slides, cervical or vaginal, definitive hormonal evaluation 88164 Cytopathology, slides, cervical or vaginal (the Bethesda System); manual screening Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and 88165 rescreening Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and 88166 computer-assisted rescreening Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and 88167 computer-assisted rescreening using cell selection and review Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated 88174 thin layer preparation; screening by automated system Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated 88175 thin layer preparation; with screening by automated system and manual rescreening or review G0101 Cervical or vaginal cancer screening; pelvic and clinical breast examination Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, G0123 automated thin layer preparation Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, G0124 automated thin layer preparation, requiring interpretation by physician Screening cytopathology smears, cervical or vaginal, performed by automated system, with manual G0141 rescreening, requiring interpretation by physician Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, G0143 automated thin layer preparation, with manual screening and rescreening Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, G0144 automated thin layer preparation, with screening by automated system Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, G0145 automated thin layer preparation, with screening by automated system and manual rescreening G0147 Screening cytopathology smears, cervical or vaginal, performed by automated system Revised 06/09/14 5 Preventive Services CPT/HCPCS Code G0148 Q0091 Description Screening cytopathology smears, cervical or vaginal, performed by automated system with manual rescreening Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory Chlamydia and Gonorrhea: Women age 24 & younger or 25 & older at increased risk The below CPT codes are considered preventive when billed with one of the following - ICD-9 code V74.5 (Screening examination for venereal disease) or ICD-10 code Z11.3 (Encounter for screening for infections with a predominantly sexual mode of transmission): CPT Code Description 87110 Culture, chlamydia, any source 87270 Infectious agent antigen detection by immunofluorescent technique Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, 87320 multiple-step method 87490 Infectious agent detection by nucleic acid (DNA or RNA); direct probe technique 87491 Infectious agent detection by nucleic acid (DNA or RNA); amplified probe technique 87492 Infectious agent detection by nucleic acid (DNA or RNA); quantification Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, direct probe 87590 technique Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe 87591 technique Infectious agent antigen detection by immunoassay with direct optical observation; Neisseria 87850 gonorrhoeae Colorectal Cancer: Adults ages 50-75 The below CPT/HCPCS codes are considered preventive when billed with one of the following - ICD-9 code V76.51 (Special screening for malignant neoplasms, colon) or ICD-10 code Z12.11 (Encounter for screening for malignant neoplasm of colon): CPT/HCPCS Code Description 00810 Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen(s) by brushing or 45330 washing 45331 Sigmoidoscopy, flexible; with biopsy, single or multiple 45332 Sigmoidoscopy, flexible; with removal of foreign body Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps 45333 or bipolar cautery Sigmoidoscopy, flexible; with control of bleeding (e.g., injection, bipolar cautery, unipolar cautery, 45334 laser, heater probe, stapler, plasma coagulator) 45335 Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance 45337 Sigmoidoscopy, flexible; with decompression of volvulus, any method 45338 Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to 45339 removal by hot biopsy forceps, bipolar cautery or snare technique 45340 Sigmoidoscopy, flexible; with dilation by balloon, 1 or more strictures 45341 Sigmoidoscopy, flexible; with endoscopic ultrasound examination Sigmoidoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine 45342 needle aspiration/biopsy(s) 45355 Colonoscopy, rigid or flexible, transabdominal via colotomy, single or multiple Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of 45378 specimen(s) by brushing or washing, with or without colon decompression (separate procedure 45379 Colonoscopy, flexible, proximal to splenic flexure; with removal of foreign body 45380 Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple Revised 06/09/14 6 Preventive Services CPT/HCPCS Code 45381 45382 45383 45384 45385 45386 45387 45391 45392 74263 82270 82274 G0104 G0105 G0106 G0120 G0121 G0122 Description Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding (e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique Colonoscopy, flexible, proximal to splenic flexure; with dilation by balloon, 1 or more strictures Colonoscopy, flexible, proximal to splenic flexure; with transendoscopic stent placement (includes predilation) Colonoscopy, flexible, proximal to splenic flexure; with endoscopic ultrasound examination Colonoscopy, flexible, proximal to splenic flexure; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s) Computed tomographic (CT) colonography, screening, including image postprocessing Blood, occult, by peroxidase activity (e.g., guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations Colorectal cancer screening; flexible sigmoidoscopy Colorectal cancer screening; colonoscopy on individual at high risk Colorectal cancer screening; alternative to G0104, screening sigmoidoscopy, barium enema Colorectal cancer screening; alternative to G0105, screening colonoscopy, barium enema Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk Colorectal cancer screening; barium enema Depression: Adults ages 18 and older The below CPT/HCPCS codes are considered preventive: CPT Code Description Initial comprehensive preventive medicine evaluation and management of an individual including an age 99385 and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 18-39 years Initial comprehensive preventive medicine evaluation and management of an individual including an age 99386 and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 40-64 years Initial comprehensive preventive medicine evaluation and management of an individual including an age 99387 and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 65 years and older Periodic comprehensive preventive medicine reevaluation and management of an individual including an 99395 age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18-39 years Periodic comprehensive preventive medicine reevaluation and management of an individual including an 99396 age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction 99397 interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and older G0444 Annual depression screening, 15 minutes Revised 06/09/14 7 Preventive Services Hepatitis B Virus: Pregnant women The below CPT codes are considered preventive when billed with one of the below ICD-9 or ICD-10 codes: CPT Code Description 86704 Hepatitis B core antibody (HBcAb); total 86706 Hepatitis B surface antibody (HBsAb) 86707 Hepatitis Be antibody (HBeAb) ICD-9 Diagnosis Code V22.0 V22.1 V22.2 V23.0 V23.1 V23.2 V23.3 V23.41 V23.49 V23.5 V23.7 V23.81 V23.82 V23.83 V23.84 V23.85 V23.86 V23.89 V23.9 Description Supervision of normal pregnancy Supervision of other than normal pregnancy Pregnant state, incidental Pregnancy with history of infertility Pregnancy with history of trophoblastic disease Pregnancy with history of abortion Grand multiparity Pregnancy with history of labor pre-term Pregnancy with other poor obstetric history Pregnancy with other poor reproductive history Insufficient prenatal care Elderly primigravida Elderly multigravida Young primigravida Young multigravida Pregnancy resulting from assisted reproductive technology Pregnancy with history of in-utero procedure during previous pregnancy Other high-risk pregnancy Unspecified high-risk pregnancy The following ICD-10 codes are effective for dates of service on or after October 1, 2015: ICD-10 Diagnosis Code Description O09.00 - O09.93 Supervision of high risk pregnancy Z33.1 Pregnant state, incidental Z34.00 - Z34.93 Encounter for supervision of normal pregnancy Hepatitis C Virus: Persons at high risk for infection or a one-time screening for adults born between 1945 and 1965 The below CPT code is considered preventive: CPT Code Description 86803 Hepatitis C antibody HIV: Adolescents and adults at increased risk and Pregnant Women HIV screenings should be performed in adolescents and adults ages 15-65. Younger adolescents and older adults should be screened if they're at a higher risk. The below CPT codes are considered preventive: CPT Code Description 86689 Antibody; HTLV or HIV antibody, confirmatory test (e.g., Western Blot) 86701 Antibody; HIV-1 86702 Antibody; HIV-2 86703 Antibody; HIV-1 and HIV-2, single assay Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, 87390 multiple-step method; HIV-1 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, 87391 multiple-step method; HIV-2 Revised 06/09/14 8 Preventive Services Lipid Disorders in Adults: Men ages 35 and older, Men ages 20-34 with an increased risk for coronary heart disease (CHD), Women ages 45 and older, and Women ages 20-44 with an increased risk for CHD The below CPT codes are considered preventive when billed with one of the following - ICD-9 code V77.91 (Screening for lipoid disorders) or ICD-10 code Z13.220 (Encounter for screening for lipoid disorders): CPT Code Description 80061 Lipid panel 82465 Cholesterol, serum or whole blood, total 83718 Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) 83719 Lipoprotein, direct measurement; VLDL cholesterol 83721 Lipoprotein, direct measurement; LDL cholesterol 84478 Triglycerides Lung Cancer Screening: Adults ages 55 to 80 who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years The below HCPCS code is considered preventive when billed with one of the following - ICD-9 code V15.82 (History of tobacco use) or V76.0 (Special screening for malignant neoplasms, respiratory organs) or ICD-10 code Z87.891 (Personal history of nicotine dependence) or Z12.2 (Encounter for screening for malignant neoplasm of respiratory organs): HCPCS Code Description S8092 Electron beam computed tomography (also known as Ultrafast CT, Cine CT) Obesity Screening: Adults The below CPT codes are considered preventive: CPT Code Description Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor 99385 reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 18-39 years Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor 99386 reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 40-64 years Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor 99387 reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 65 years and older Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor 99395 reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 1839 years Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor 99396 reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 4064 years Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor 99397 reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and older Osteoporosis: Postmenopausal Women ages 65 and older with no risk factors or ages 60 and older with risk factors The below CPT codes are considered preventive: CPT Code Description Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, 77078 spine) Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (e.g., hips, 77080 pelvis, spine) Revised 06/09/14 9 Preventive Services CPT Code 77081 77082 Description Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel) Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; vertebral fracture assessment Screening for Gonorrhea and Syphilis (Pregnant Women) The below CPT codes are considered preventive when billed with one of the below ICD-9 or ICD-10 codes: CPT Code Description 86592 Syphilis test, non-treponemal antibody; qualitative 87590 Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, direct probe technique Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe 87591 technique 87850 Infectious agent antigen detection by immunoassay with direct optical observation; Neisseria gonorrhoeae ICD-9 Diagnosis Code V22.0 V22.1 V22.2 V23.0 V23.1 V23.2 V23.3 V23.41 V23.49 V23.5 V23.7 V23.81 V23.82 V23.83 V23.84 V23.85 V23.86 V23.89 V23.9 Description Supervision of normal pregnancy Supervision of other than normal pregnancy Pregnant state, incidental Pregnancy with history of infertility Pregnancy with history of trophoblastic disease Pregnancy with history of abortion Grand multiparity Pregnancy with history of labor pre-term Pregnancy with other poor obstetric history Pregnancy with other poor reproductive history Insufficient prenatal care Elderly primigravida Elderly multigravida Young primigravida Young multigravida Pregnancy resulting from assisted reproductive technology Pregnancy with history of in-utero procedure during previous pregnancy Other high-risk pregnancy Unspecified high-risk pregnancy The following ICD-10 codes are effective for dates of service on or after October 1, 2015: ICD-10 Diagnosis Code Description O09.00 - O09.93 Supervision of high risk pregnancy Z11.3 Encounter for screening for infections with a predominantly sexual mode of transmission Z33.1 Pregnant state, incidental Z34.00 - Z34.93 Encounter for supervision of normal pregnancy Sexually Transmitted Infections (STI) Screening The below CPT codes are considered preventive: CPT Code Description 87270 Infectious agent antigen detection by immunofluorescent technique; Chlamydia trachomatis Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, 87320 multiple-step method; Chlamydia trachomatis 86255 Fluorescent noninfectious agent antibody; screen, each antibody 86256 Fluorescent noninfectious agent antibody; titer, each antibody 86592 Syphilis test, non-treponemal antibody; qualitative Revised 06/09/14 10 Preventive Services CPT Code 86689 86701 86702 86703 Description Antibody; HTLV or HIV antibody, confirmatory test (e.g., Western Blot) Antibody; HIV-1 Antibody; HIV-2 Antibody; HIV-1 and HIV-2, single assay Syphilis: Men and Women at increased risk The below CPT code is considered preventive when billed with one of the following - ICD-9 code V74.5 (Screening examination for venereal disease) or ICD-10 code Z11.3 (Encounter for screening for infections with a predominantly sexual mode of transmission): CPT Code Description 86592 Syphilis test, non-treponemal antibody; qualitative (e.g., VDRL, RPR, ART) Type 2 Diabetes Mellitus: Men and Women - Sustained BP 135/80+ The below CPT codes are considered preventive when billed with one of the following - ICD-9 code V77.1 (Screening for diabetes mellitus) or ICD-10 code Z13.1 (Encounter for screening for diabetes mellitus): CPT Code Description 82947 Glucose; quantitative, blood (except reagent strip) 82948 Glucose; blood, reagent strip ROUTINE HEALTH SCREENINGS: PEDIATRIC Congenital Hypothyroidism Screening: Newborns Included in inpatient evaluation and management services for newborns Depression: Adolescents ages 12-17 The below CPT/HCPCS codes are considered preventive: CPT Code Description Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction 99384 interventions, and the ordering of laboratory/diagnostic procedures, new patient; adolescent (age 12 through 17 years) Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction 99394 interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 years) G0444 Annual depression screening, 15 minutes Developmental/Behavioral Assessment In addition to the above CPT codes, the below CPT code is considered preventive: CPT Code Description Developmental testing; limited (e.g., Developmental Screening Test II, Early Language Milestone 96110 Screen), with interpretation and report Dyslipidemia The below CPT codes are considered preventive when billed with one of the following - ICD-9 code V77.91 (Screening for lipoid disorders) or ICD-10 code Z13.220 (Encounter for screening for lipoid disorders): CPT Code Description 80061 Lipid panel 82465 Cholesterol, serum or whole blood, total 83718 Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) 83719 Lipoprotein, direct measurement; VLDL cholesterol 83721 Lipoprotein, direct measurement; LDL cholesterol 84478 Triglycerides Hearing Loss Screening: Newborns Included in inpatient evaluation and management services for newborns Revised 06/09/14 11 Preventive Services Hemocrit or Hemoglobin The below CPT codes are considered preventive: CPT Code Description 85014 Blood count; hematocrit 85018 Blood count; hemoglobin 85013 Blood count; spun microhematocrit Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated 85025 differential WBC count 85027 Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) Lead The below CPT code is considered preventive when billed with one of the following - ICD-9 code V82.5 (Screening for chemical poisoning and other contamination) or ICD-10 code Z13.88 (Encounter for screening for disorder due to exposure to contaminants): CPT Code Description 83655 Lead Metabolic/Hemoglobin Screening: Newborns The below CPT codes are considered preventive: CPT Code Description Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated 85025 differential WBC count 85018 Blood count; hemoglobin 85013 Blood count; spun microhematocrit Obesity Screening: Children and Adolescents ages 6-17 The below CPT codes are considered preventive: CPT Code Description Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction 99383 interventions, and the ordering of laboratory/diagnostic procedures, new patient; late childhood (age 5 through 11 years) Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction 99384 interventions, and the ordering of laboratory/diagnostic procedures, new patient; adolescent (age 12 through 17 years) Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction 99393 interventions, and the ordering of laboratory/diagnostic procedures, established patient; late childhood (age 5 through 11 years) Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction 99394 interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 years) Phenylketonuria Screening: Newborns Included in inpatient evaluation and management services for newborns Skin Cancer Behavioral Counseling: Children, Adolescents and Young Adults ages 10 to 24 Included in preventive evaluation and management visit Tuberculin Test The below CPT codes are considered preventive: CPT Code Description 86580 Skin test; tuberculosis, intradermal 86480 Tuberculosis test, cell mediated immunity measurement of gamma interferon antigen response Revised 06/09/14 12 Preventive Services Visual Acuity Screening: Children ages 3 to 5 The below CPT code is considered preventive: CPT Code Description 99173 Screening test of visual acuity, quantitative, bilateral Visual Impairment: Children younger than 5 The below CPT codes are considered preventive: CPT Code Description Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction 99381 interventions, and the ordering of laboratory/diagnostic procedures, new patient; infant (age younger than 1 year) Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction 99382 interventions, and the ordering of laboratory/diagnostic procedures, new patient; early childhood (age 1 through 4 years) Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction 99391 interventions, and the ordering of laboratory/diagnostic procedures, established patient; infant (age younger than 1 year) Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction 99392 interventions, and the ordering of laboratory/diagnostic procedures, established patient; early childhood (age 1 through 4 years) PREVENTIVE IMMUNIZATIONS All immunizations are subject to availability. Refer to our List of Unavailable Vaccines and Drugs policy for additional information. Pediatric and Adolescent Immunizations The below pediatric and adolescent immunizations are considered preventive: Immunization/Vaccine CPT Code Description Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), when 90700 administered to individuals younger than 7 years, for intramuscular use Diphtheria and tetanus toxoids (DT) adsorbed when administered to 90702 individuals younger than 7 years, for intramuscular use DTP Tetanus and diphtheria toxoids (Td) adsorbed, preservative free, when 90714 administered to individuals 7 years or older, for intramuscular use Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when 90715 administered to individuals 7 years or older, for intramuscular use 90719 Diphtheria toxoid, for intramuscular use Hemophilus influenza b vaccine (Hib), HbOC conjugate (4 dose schedule), 90645 for intramuscular use Hemophilus influenza b vaccine (Hib), PRP-D conjugate, for booster use 90646 only, intramuscular use Hemophilus Influenza Type B Hemophilus influenza b vaccine (Hib), PRP-T conjugate (4 dose schedule), 90647 for intramuscular use Hemophilus influenza b vaccine (Hib), PRP-T conjugate (4 dose schedule), 90648 for intramuscular use Hepatitis A vaccine, pediatric/adolescent dosage-2 dose schedule, for 90633 intramuscular use Hepatitis A Hepatitis A vaccine, pediatric/adolescent dosage-3 dose schedule, for 90634 intramuscular use Hepatitis B 90743 Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use Revised 06/09/14 13 Preventive Services Immunization/Vaccine CPT Code 90744 90649 HPV: ages 9-26 90650 Inactivated Poliovirus 90713 Q2035 Q2036 Q2037 Q2038 Q2039 90653 90654 90655 90656 Influenza 90657 90658 90660 90661 90662 90664 90672 90673 90688 90644 Meningococcal 90733 90734 MMR (Measles, Mumps, Rubella) MMRV (Measles, mumps, rubella, and varicella) Revised 06/09/14 90707 90710 Description Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use Human Papilloma virus (HPV) vaccine, types 6, 11, 16, 18 (quadrivalent), 3 dose schedule, for intramuscular use Human Papilloma virus (HPV) vaccine, types 16, 18, bivalent, 3 dose schedule, for intramuscular use Poliovirus vaccine, inactivated (IPV), for subcutaneous or intramuscular use Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (AFLURIA) Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (FLULAVAL) Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (FLUVIRIN) Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone) Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (not otherwise specified) Influenza vaccine, inactivated, subunit, adjuvanted, for intramuscular use Influenza virus vaccine, split virus, preservative-free, for intradermal use Influenza virus vaccine, split virus, preservative-free, when administered to children 6-35 months of age, for intramuscular use Influenza virus vaccine, split virus, preservative-free, when administered to individuals 3 years and older, for intramuscular use Influenza virus vaccine, split virus, when administered to children 6-35 months of age, for intramuscular use Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use Influenza virus vaccine, live, for intranasal use Influenza virus vaccine, derived from cell cultures, subunit, preservative and antibiotic free, for intramuscular use Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use Influenza virus vaccine, pandemic formulation, live, for intranasal use Influenza virus vaccine, quadrivalent, live, for intranasal use Influenza virus vaccine, trivalent, derived from recombinant DNA (RIV3), hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use Influenza virus vaccine, quadrivalent, split virus, when administered to individuals 3 years of age and older, for intramuscular use Meningococcal conjugate vaccine, serogroups C & Y and Hemophilus influenza b vaccine, tetanus toxoid conjugate (Hib-MenCY-TT), 4-dose schedule, when administered to children 2-15 months of age, for intramuscular use Meningococcal polysaccharide vaccine (any group(s)), for subcutaneous use Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 (tetravalent), for intramuscular use Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use 14 Preventive Services Immunization/Vaccine Rotavirus Varicella CPT Code 90680 90681 90716 Description Rotavirus vaccine, pentavalent, 3 dose schedule, live, for oral use Rotavirus vaccine, human, attenuated, 2 dose schedule, live, for oral use Varicella virus vaccine, live, for subcutaneous use Adult Immunizations The following adult immunizations are considered preventive: Immunization/Vaccine CPT Code Description Tetanus and diphtheria toxoids (Td) adsorbed, preservative free, when 90714 administered to individuals 7 years or older, for intramuscular use Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when 90715 administered to individuals 7 years or older, for intramuscular use DTP Tetanus and diphtheria toxoids (Td) adsorbed when administered to 90718 individuals 7 years or older, for intramuscular use 90719 Diphtheria toxoid, for intramuscular use Hepatitis A 90632 Hepatitis A vaccine, adult dosage, for intramuscular use 90739 Hepatitis B vaccine, adult dosage (2 dose schedule), for intramuscular use 90746 Hepatitis B vaccine, adult dosage, for intramuscular use Hepatitis B Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose 90747 schedule), for intramuscular use Hepatitis A and hepatitis B vaccine (HepA-HepB), adult dosage, for Hepatitis A and B 90636 intramuscular use Human Papilloma virus (HPV) vaccine, types 6, 11, 16, 18 (quadrivalent), 3 90649 dose schedule, for intramuscular use HPV: ages 9-26 Human Papilloma virus (HPV) vaccine, types 16, 18, bivalent, 3 dose 90650 schedule, for intramuscular use 90653 Influenza vaccine, inactivated, subunit, adjuvanted, for intramuscular use 90654 Influenza virus vaccine, split virus, preservative-free, for intradermal use Influenza virus vaccine, split virus, preservative free, when administered 90656 to individuals 3 years and older, for intramuscular use Influenza virus vaccine, split virus, when administered to individuals 3 90658 years of age and older, for intramuscular use 90660 Influenza virus vaccine, live, for intranasal use Influenza virus vaccine, derived from cell cultures, subunit, preservative 90661 and antibiotic free, for intramuscular use Influenza virus vaccine, split virus, preservative free, enhanced 90662 immunogenicity via increased antigen content, for intramuscular use 90672 Influenza virus vaccine, quadrivalent, live, for intranasal use Influenza virus vaccine, trivalent, derived from recombinant DNA (RIV3), Influenza 90673 hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use Influenza virus vaccine, quadrivalent, split virus, when administered to 90688 individuals 3 years of age and older, for intramuscular use Influenza virus vaccine, split virus, when administered to individuals 3 Q2035 years of age and older, for intramuscular use (AFLURIA) Influenza virus vaccine, split virus, when administered to individuals 3 Q2036 years of age and older, for intramuscular use (FLULAVAL) Influenza virus vaccine, split virus, when administered to individuals 3 Q2037 years of age and older, for intramuscular use (FLUVIRIN) Influenza virus vaccine, split virus, when administered to individuals 3 Q2038 years of age and older, for intramuscular use (Fluzone) Influenza virus vaccine, split virus, when administered to individuals 3 Q2039 years of age and older, for intramuscular use (not otherwise specified) Revised 06/09/14 15 Preventive Services Immunization/Vaccine CPT Code 90733 Meningococcal 90734 MMR (Measles, Mumps, Rubella) MMRV (Measles, mumps, rubella, and varicella) Pneumoccocal (polysaccharide) Varicella Zoster 90707 90710 90669 90670 90732 90716 90736 Description Meningococcal polysaccharide vaccine (any group(s)), for subcutaneous use Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 (tetravalent), for intramuscular use Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use Pneumococcal conjugate vaccine, 7 valent, for intramuscular use Pneumococcal conjugate vaccine, 13 valent, for intramuscular use Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use Varicella virus vaccine, live, for subcutaneous use Zoster (shingles) vaccine, live, for subcutaneous injection Preventive Immunization Administration Codes The below CPT codes are considered preventive: CPT Code Description Immunization administration through 18 years of age via any route of administration, with counseling 90460 by physician or other qualified health care professional; first vaccine/toxoid component Immunization administration through 18 years of age via any route of administration, with counseling 90461 by physician or other qualified health care professional; each additional vaccine/toxoid component (List separately in addition to code for primary procedure) Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular 90471 injections); 1 vaccine (single or combination vaccine/toxoid) Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular 90472 injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure) Immunization administration by intranasal or oral route; 1 vaccine (single or combination 90473 vaccine/toxoid) Immunization administration by intranasal or oral route; each additional vaccine (single or combination 90474 vaccine/toxoid) (List separately in addition to code for primary procedure) COUNSELING SERVICES Alcohol Misuse: Screening and Behavioral Counseling for Adults The below CPT/HCPCS codes are considered preventive: CPT Code Description Alcohol and/or substance (other than tobacco) abuse structured screening (e.g., AUDIT, DAST), and brief 99408 intervention (SBI) services; 15 to 30 minutes Alcohol and/or substance (other than tobacco) abuse structured screening (e.g., AUDIT, DAST), and brief 99409 intervention (SBI) services; greater than 30 minutes G0442 Annual alcohol misuse screening, 15 minutes G0443 Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes Aspirin Counseling: Men ages 45 to 79 (for the prevention of myocardial infarctions), and Women ages 55 to 78 (for the prevention of ischemic strokes) The below CPT codes are considered preventive: CPT Code Description Initial comprehensive preventive medicine evaluation and management of an individual including an age 99386 and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 40-64 years Revised 06/09/14 16 Preventive Services CPT Code 99387 99396 99397 Description Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 65 years and older Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and older BRCA Genetic Counseling The below CPT/HCPCS codes are considered preventive when billed with one of the following - ICD-9 code V16.3 (Family history of malignant neoplasm, breast) or V16.41 (Family history of malignant neoplasm, genital organs, ovary) or ICD10 code Z80.3 (Family history of malignant neoplasm of breast) or Z80.41 (Family history of malignant neoplasm of ovary): CPT/HCPCS Code Description 96040 Medical genetics and genetic counseling services, each 30 minutes face-to-face with patient/family S0265 Genetic counseling, under physician supervision, each 15 minutes Healthy Diet: Counseling - Adults with hyperlipidemia and other risk factors for cardiovascular disease and dietrelated chronic disease The below CPT/HCPCS codes are considered preventive: CPT Code Description Initial comprehensive preventive medicine evaluation and management of an individual including an age 99385 and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 18-39 years Initial comprehensive preventive medicine evaluation and management of an individual including an age 99386 and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 40-64 years Initial comprehensive preventive medicine evaluation and management of an individual including an age 99387 and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 65 years and older Periodic comprehensive preventive medicine reevaluation and management of an individual including an 99395 age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18-39 years Periodic comprehensive preventive medicine reevaluation and management of an individual including an 99396 age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction 99397 interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and older Intensive behavioral therapy to reduce cardiovascular disease risk, individual, face-to-face, annual, 15 G0446 minutes Obesity: Counseling The below CPT/HCPCS codes are considered preventive: CPT Code Description Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual 99401 (separate procedure); approximately 15 minutes Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual 99402 (separate procedure); approximately 30 minutes Revised 06/09/14 17 Preventive Services CPT Code 99403 99404 G0447 Description Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 45 minutes Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 60 minutes Face-to-face behavioral counseling for obesity, 15 minutes Prenatal: Counseling The below CPT codes are considered preventive: CPT Code Description Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual 99401 (separate procedure); approximately 15 minutes Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual 99402 (separate procedure); approximately 30 minutes Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual 99403 (separate procedure); approximately 45 minutes Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual 99404 (separate procedure); approximately 60 minutes Tobacco Use: Counseling and intervention for Children, Adolescents and Adults (including Pregnant Women) The below CPT/HCPCS codes are considered preventive: CPT Code Description Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 G0436 minutes, up to 10 minutes Smoking and tobacco cessation counseling visit for the asymptomatic patient; intensive, greater than 10 G0437 minutes S9453 Smoking cessation classes, non-physician provider, per session Physician educational services rendered to patients in a group setting (e.g., prenatal, obesity, or diabetic 99078 instructions) Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction 99383 interventions, and the ordering of laboratory/diagnostic procedures, new patient; late childhood (age 5 through 11 years) Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction 99384 interventions, and the ordering of laboratory/diagnostic procedures, new patient; adolescent (age 12 through 17 years) Initial comprehensive preventive medicine evaluation and management of an individual including an age 99385 and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 18-39 years Initial comprehensive preventive medicine evaluation and management of an individual including an age 99386 and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 40-64 years Initial comprehensive preventive medicine evaluation and management of an individual including an age 99387 and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 65 years and older Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction 99393 interventions, and the ordering of laboratory/diagnostic procedures, established patient; late childhood (age 5 through 11 years) Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction 99394 interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 years) Revised 06/09/14 18 Preventive Services CPT Code 99395 99396 99397 99406 99407 Description Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18-39 years Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and older Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes Sexually Transmitted Infections: Behavioral Counseling - Sexually Active Adolescents and Adults at increased risk The below CPT/HCPCS codes are considered preventive: CPT Code Description Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual 99401 (separate procedure); approximately 15 minutes Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual 99402 (separate procedure); approximately 30 minutes Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual 99403 (separate procedure); approximately 45 minutes Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual 99404 (separate procedure); approximately 60 minutes High intensity behavioral counseling to prevent sexually transmitted infection; face-to-face, individual, G0445 includes: education, skills training and guidance on how to change sexual behavior; performed semiannually, 30 minutes PHARMACY U.S. Preventive Services Task Force A & B Recommendation Medications Tufts Health Plan has included certain categories of medications in the preventive services coverage based on recommendations from the U.S. Preventive Services Task Force and the Institute of Medicine. These preventive medications are covered under the Patient Protection and Affordable Care Act at no cost ($0 copayment) to Members when prescribed by a licensed provider and filled at a network pharmacy. Coverage limitations such as age and gender rules apply, see Special Coverage Considerations for details below. This coverage does not apply to members of “grandfathered” plans. Note: Preventive over-the-counter (OTC) medications are covered in full when prescribed by a licensed Provider and dispensed at a pharmacy pursuant to a prescription. Medication Aspirin ≤ 325 mg Applies To OTC Generic Only Fluoride drops & tablets Rx Brands and Generics Folic acid 0.4 mg, 0.8 mg, 1mg Iron liquid supplements Preventive medications for the risk reduction of primary breast cancer in women: Evista, Soltamox, Raloxifene and Tamoxifen Prescription smoking cessation products Revised 06/09/14 OTC and Rx Generic Only OTC Brands and Generics Special Coverage Considerations Covered in full for Members age 45 years and older Covered in full for preschool children age 6 months through age 6 Covered in full for women of childbearing age (12 – 52 years) Covered in full for children up to 12 months of age Rx Brands and Generics Covered in full for women Rx Brands and Generics Covered in full. Quantity limitations may apply. 19 Preventive Services Medication Vitamin D 400 unit capsules, drops and tablets; 400 unit/ mL oral liquid; 1,000 unit/ 10 mL oral liquid; 1,200 unit/ 15 mL oral liquid Applies To Special Coverage Considerations OTC Brands and Generics Covered in full for Members age 65 years and older FDA-Approved Over-the-Counter (OTC) Contraceptives for Women These preventive medications are covered under the Patient Protection and Affordable Care Act at no cost ($0 copayment) to female Members when prescribed by a licensed Provider and dispensed at a network pharmacy pursuant to a prescription. This coverage does not apply to members of “grandfathered” plans, and certain religious group employers are exempt from the requirement to cover contraceptive services. Contraceptive films Contraceptive foams Contraceptive gels Emergency contraceptives Female condoms Prescription Contraceptives for Women Contraceptives, including oral contraceptives, diaphragms, and other self-administered hormonal contraceptives (e.g., patches, rings) that by law require a prescription are covered in full for women under the Pharmacy Benefit ($0 copayment). Contraceptives that are administered by a health care professional, including cervical caps, IUDs and implantable contraceptives that by law require a prescription are covered in full for women under the Medical Benefit. For additional information, see the Women’s Health section of this Preventive Services Payment Policy. This coverage does not apply to members of “grandfathered” plans, and certain religious group employers are exempt from the requirement to cover contraceptive services. Note: Male contraceptives are not covered under the Patient Protection and Affordable Care Act. WOMEN’S HEALTH Beginning August 1, 2012, and effective on the member’s plan renewal date, Tufts Health Plan will cover the women’s preventive health care services as indicated in this section, with no cost share for most members when those services are rendered by a provider in the member’s plan network. Outpatient Maternity Services Beginning January 1, 2014, for new groups and upon plan renewal date for existing members of all fully and self-insured non-grandfathered plans all outpatient routine prenatal and postpartum office visits will be covered in full. Any outpatient maternity services not considered routine or those related to complications or risks with a pregnancy, may be subject to cost sharing based on the member’s plan. Some examples of services not considered routine include, but are not limited to, amniocentesis, fetal stress testing, and OB ultrasounds. Note: This does not include inpatient maternity services which may be subject to cost share based on member’s plan design. The below CPT codes are considered routine: CPT Code Description Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or 59400 forceps) and postpartum care Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care 59410 59425 Antepartum care only; 4-6 visits 59426 Antepartum care only; 7 or more visits 59430 Postpartum care only (separate procedure) 59510 Routine obstetric care including antepartum care, cesarean delivery, and postpartum care 59515 Cesarean delivery only; including postpartum care Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or 59610 forceps) and postpartum care, after previous cesarean delivery Revised 06/09/14 20 Preventive Services CPT Code 59614 59618 59622 Description Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery; including postpartum care Breastfeeding support, supplies and counseling for pregnant and postpartum Women The below HCPCS codes are considered preventive: CPT Code Description A4281 Tubing for breast pump, replacement A4282 Adapter for breast pump, replacement A4283 Cap for breast pump bottle, replacement A4284 Breast shield and splash protector for use with breast pump, replacement A4285 Polycarbonate bottle for use with breast pump, replacement A4286 Locking ring for breast pump, replacement E0602 Breast pump, manual, any type E0603 Breast pump, electric (AC and/or DC), any type E0604 Breast pump, hospital grade, electric (AC and/or DC), any type S9443 Lactation classes, nonphysician provider, per session Contraception and Contraceptive Counseling FDA-approved over-the-counter female contraceptives are considered preventive when prescribed by a licensed provider and dispensed at a pharmacy pursuant to a prescription. Emergency contraceptives, including Ella® and generics of Plan B® and Plan B One-Step® are considered preventive. The below CPT codes are considered preventive when billed with one of the following - ICD-9 code V25.2 (Sterilization) or ICD-10 code Z30.2 (Encounter for sterilization): CPT Code Description 00952 Anesthesia for vaginal procedures; hysteroscopy and/or hysterosalpingography 58555 Hysteroscopy, diagnostic Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of 58565 permanent implants 58600 Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral Ligation or transection of fallopian tube(s), abdominal or vaginal approach, postpartum, unilateral or 58605 bilateral, during same hospitalization Ligation or transection of fallopian tube(s) when done at the time of cesarean delivery or intra58611 abdominal surgery (not a separate procedure) 58615 Occlusion of fallopian tube(s) by device (e.g., band, clip, Falope ring) vaginal or suprapubic approach 58670 Laparoscopy, surgical; with fulguration of oviducts (with or without transection) 58671 Laparoscopy, surgical; with occlusion of oviducts by device (e.g., band, clip, or Falope ring) Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; tubal 00851 ligation/transection Level II - Surgical pathology, gross and microscopic examination Appendix, incidental, Fallopian tube, 88302 sterilization 99144* Moderate sedation age 5 years or older, first 30 minutes intra-service time 99145* Moderate sedation each additional 15 minutes intra-service time A4264 Permanent implantable contraceptive intratubal occlusion device(s) and delivery system *Considered preventive when billed with CPT code 58555 or 00952. Revised 06/09/14 21 Preventive Services The below CPT/HCPCS codes are considered preventive when billed with one of the below ICD-9 codes or ICD-10 codes: CPT Code Description 11976 Removal, Implantable contraceptive capsules Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets 11980 beneath the skin) 11981 Insertion, non-biodegradable drug delivery implant 11982 Removal, non-biodegradable drug delivery implant 11983 Removal with reinsertion, non-biodegradable drug delivery implant 57170 Diaphragm & cervical cap fitting 58300 Insertion of IUD 58301 Removal of IUD Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or 96372 intramuscular Office or other outpatient visit for the evaluation and management of an established patient, that may 99211 not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services. A4261 Cervical cap for contraceptive use A42661 Diaphragm for contraceptive use 1 A4268 Contraceptive supply, condom, female, each A42691 Contraceptive supply, spermicide (e.g., foam, gel), each J1050 Injection, medroxyprogesterone acetate, 1 mg (Depo-Provera) J7300 Intrauterine Copper Contraceptive J7301 Levonorgestrel-releasing intrauterine contraceptive system (Skyla), 13.5 mg J7302 Levonorgestrel 52 mg intrauterine device releases levonorgestrel 20 mcg/day (Mirena) J73031 Contraceptive supply, hormone containing vaginal ring, each 1 J7304 Contraceptive supply, hormone containing patch, each J7307 Etonogestrel (contraceptive) implant system, including implant and supplies S4989 Contraceptive intrauterine device (e.g., Progestacert IUD, including implants and supplies) S4993 Contraceptive pills for birth control ICD-9 Diagnosis Code V25.02 V25.11 - V25.13 V25.40 – V25.43 V25.9 V45.51 V45.52 Description Initiation of other contraceptive measures Encounter for insertion or removal of intrauterine contraceptive device Surveillance of previously prescribed contraceptive methods Unspecified contraceptive management Intrauterine contraceptive device Subdermal contraceptive implant The following ICD-10 codes are effective for dates of service on or after October 1, 2015: ICD-10 Diagnosis Code Description Z30.013 – Z30.019 Encounter for initial prescription of contraceptives Z30.4 – Z30.9 Encounter for surveillance of contraceptives or Encounter for contraceptive management Z97.5 Presence of (intrauterine) contraceptive device Domestic Violence Screening for domestic violence covered as part of the annual well-woman visit. Gestational Diabetes The below CPT codes are considered preventive when billed with one of the below ICD-9 or ICD-10 codes: CPT Code Description 80422 Glucagon tolerance panel; for insulinoma 1 Covered under the Pharmacy benefit. Revised 06/09/14 22 Preventive Services CPT Code 82950 82951 82952 ICD-9 Diagnosis Code V22.0 V22.1 V22.2 V23.0 V23.1 V23.2 V23.3 V23.41 V23.49 V23.5 V23.7 V23.81 V23.82 V23.83 V23.84 V23.85 V23.86 V23.89 V23.9 Description Glucose; post glucose dose (includes glucose) Glucose; tolerance test (GTT), 3 specimens (includes glucose) Glucose; tolerance test, each additional beyond 3 specimens (List separately in addition to code for primary procedure) Description Supervision of normal pregnancy Supervision of other than normal pregnancy Pregnant state, incidental Pregnancy with history of infertility Pregnancy with history of trophoblastic disease Pregnancy with history of abortion Grand multiparity Pregnancy with history of labor pre-term Pregnancy with other poor obstetric history Pregnancy with other poor reproductive history Insufficient prenatal care Elderly primigravida Elderly multigravida Young primigravida Young multigravida Pregnancy resulting from assisted reproductive technology Pregnancy with history of in-utero procedure during previous pregnancy Other high-risk pregnancy Unspecified high-risk pregnancy The following ICD-10 codes are effective for dates of service on or after October 1, 2015: ICD-10 Diagnosis Code Description O09.00 - O09.93 Supervision of high risk pregnancy Z33.1 Pregnant state, incidental Z34.00 - Z34.93 Encounter for supervision of normal pregnancy HIV Screening and Counseling Please refer to the HIV: Adults and Adolescents and Pregnant Women section of this document. HPV DNA Testing for Women ages 30 or older The below CPT codes are considered preventive: CPT Code Description 87620 Infectious agent detection by nucleic acid (DNA or RNA) Infectious agent detection by nucleic acid (DNA or RNA); papillomavirus, human, amplified 87621 probe technique Infectious agent detection by nucleic acid (DNA or RNA); papillomavirus, human, 87623 quantification Sexually Transmitted Infections (STI) Screening and Counseling Please refer to the STI Screening and STI counseling sections of this document. Well-Woman Visit Please refer to the preventive office visit section of this document. COMPENSATION/REIMBURSEMENT INFORMATION Providers are compensated according to the Tufts Health Plan network contracted rates regardless of the address where the service is rendered. Claims are subject to payment edits that are updated at regular intervals and generally based on CMS, specialty society guidelines, drug manufacturers’ package label inserts, and National Correct Coding Initiative (CCI). Revised 06/09/14 23 Preventive Services DOCUMENT HISTORY July 3, 2013: Added CPT codes 99460, 99461, 99462, 99463, 58555, 99144, 99145 and Removed CPT code Q0090. August 7, 2013: Added CPT code 90664. September 25, 2013: Updated language. Added HCPCS codes A4268, A4269 and Removed HCPCS code J8499. October 24, 2013: Formatting changes. Added CPT Code 90661. November 5, 2013: Removed CPT code 77079. December 30, 2013: Formatting changes. Added CPT/HCPCS code(s) 90673, J7301, S0195 and Removed HCPCS code Q2033. January 7, 2014: Formatting changes. January 23, 2014: Formatting changes. March 10, 2014: Added new recommendation section(s) “BRCA Genetic Counseling” “BRCA Genetic Testing” and “Lung Cancer Screening”. March 12, 2014: Formatting changes. April 11, 2014: Added “Raloxifene” to Pharmacy Section. Removed diagnosis component requirement from Immunization section. May 30, 2014: Formatting changes. Added CPT code 84478. June 9, 2014: Formatting changes. Added CPT code 82465. Clarified coding for “Gestational Diabetes Screening” and “Type 2 Diabetes Mellitus”. Added diagnosis component to “Venipuncture” section. Revised 06/09/14 24 Preventive Services
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