Billing Guideline Subject: Preventive Services Background

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Billing GuidelineSubject: Preventive ServicesEffective: 1/1/13Last revision effective: 9/1/2017BackgroundWe are committed to the wellness of our members and encourage preventive services that can detectserious medical issues early. Certain preventive services are covered at no cost to the member due toplan provisions or regulatory requirements. These services are addressed here. For all lines ofbusiness, procedure codes recognized to report preventive services are listed, along with anyfrequency limits, diagnosis coding, or separate payment policies.Note that preventive screenings are conducted when signs or symptoms of a condition are notpresent, and in accordance with established guidelines. Testing done for diagnostic purposesmay be covered with cost-share. Be sure to verify benefits.ReferencesThe Affordable Care Act (ACA) requires full coverage of the following preventive services fornon-grandfathered plans1: Services recommended by the U.S. Preventive Services Task Force (USPSTF) with a rating ofA or B. Immunizations recommended by the Advisory Committee on Immunization Practices of theCenters for Disease Control and Prevention (CDC) for routine use in children, adolescents, andadults. Preventive care and screenings for women, infants, children, and adolescents that are providedfor in the comprehensive guidelines supported by the Health Resources and ServicesAdministration (HRSA).We continually monitor changes to preventive service guidelines and will adjust coverage as requiredby law. For an official current list of recommended preventive services, visit www.healthcare.gov.Medicare has adopted many, but not all, of these recommendations. Any differences in coverageand billing rules are noted. For details about Original Medicare coverage of preventive services, see“Medicare Preventive Services”, available y.pdf1As used in connection with the ACA, a grandfathered plan is a group health plan that was created, or anindividual health insurance policy that was purchased, on or before March 23, 2010. Grandfathered plans areexempted from many changes required under the ACA, including implementation of the preventive servicesprovisions. Health First Health Plans does not have any grandfathered plans.Revisions from last publication are highlighted in yellow.

Tips1. Preventive office visit coding: A preventive office visit must be billed with a preventive(routine) office visit E/M code. A problem-oriented E/M code will not be covered as a preventivebenefit.a. A problem-oriented E/M code will be denied if submitted with a primary preventivediagnosis code.b. A preventive E/M code will be denied if submitted with a primary problem-orienteddiagnosis code.2. Preventive and problem-oriented E/M codes billed together: Preventive E/M codes includea comprehensive exam, encompassing management of chronic and/or stable conditions,abnormal findings on review of systems, and diagnosis and treatment of minor conditions. It israre that a separate E/M code is justified because its components cannot be independently met,however when documentation is provided that supports reporting the separate service and theproblem E/M code is billed with modifier -25, separate payment may be considered.3. Diagnosis code limits: Where diagnosis code limits are indicated, payment may be denied if adifferent code is billed. Be sure to use the appropriate primary diagnosis code for each servicereported on a claim.a. If a test not clearly described as a screening exam is billed with a diagnosis code notlisted in this guideline, it may be covered as a diagnostic test with applicable cost-share.4. Frequency limits: If a preventive service is provided more often than indicated, payment maybe denied.a. If a test not clearly described as a screening exam is billed more often than indicated inthis guideline, it may be covered as a diagnostic test with applicable cost-share.IndexCategoryPreventive Office VisitsBehavioral/DevelopmentalScreeningsBehavioral CounselingServiceAnnual Wellness Visit (Medicare)Initial Preventive Physical Exam (Medicare)Prenatal and Postnatal Office VisitsPreventive Office VisitsAlcohol/Drug Misuse ScreeningDepression ScreeningDevelopmental Screening for ChildrenObesity ScreeningAlcohol/Drug Misuse CounselingBreast Cancer PreventionCardiovascular Disease (including aspirin use)Diabetes Self-Management Training Services (DSMT)Diet/NutritionFolic Acid SupplementationGenetic Counseling - BRCA for Breast CancerInterpersonal and Domestic ViolencePage #11-22-67-8888-9999101010 - 11111111Revisions from last publication are highlighted in yellow.

CategoryBehavioral CounselingcontinuedCancer ScreeningsOther Lab TestsOther ScreeningsBreastfeeding Services andSuppliesContraceptive Services andSuppliesServiceIron SupplementationObesity CounselingOral Health - ChildrenSexually Transmitted Infections (STI)Tobacco Use CounselingBreast Cancer ScreeningCervical Cancer ScreeningColorectal Cancer ScreeningLung Cancer ScreeningProstate Cancer ScreeningAnemiaBacteriuria (Urinalysis)BRCA AnalysisChlamydia ScreeningCholesterol ScreeningDiabetes ScreeningGeneral Health/Metabolic PanelsGonorrhea ScreeningHemoglobinopathies (Sickle Cell)Hepatitis B ScreeningHepatitis C ScreeningHerpes ScreeningHIV ScreeningHPV DNA TestingHypothyroidismLead ScreeningObstetric Screening PanelPKU ScreeningRH IncompatibilitySyphilis ScreeningAbdominal Aortic Aneurism (AAA) ScreeningBone Density (Osteoporosis) ScreeningGlaucoma ScreeningHearing ScreeningTuberculin TestVision ScreeningBreast PumpsBreastfeeding (Lactation) CounselingContraceptionPage #1111 - 121313141415 - 1919 - 23242424 - 25252627272828282929292930 - 3132323232323232333334343435353536 - 38Revisions from last publication are highlighted in yellow.

Billing Guideline for Preventive ServicesPreventive Office VisitsServiceDescriptionMedicareAnnualWellness Visit(AWV)PopulationMedicareFrequencyLimits1 per lifetimeafter the IPPE1 per calendaryearCPT/HCPCSCodeMedicare1 per lifetimewithin 12 monthsof MedicareenrollmentAnnual wellness visit, includingPPPS, first visitYNCategory 1G0439Annual wellness visit, includingPPPS, subsequent visitYNCategory 199497*Advance care planning, including theexplanation and discussion ofadvance directives such as standardforms (with completion of such forms,when performed), by a physician orother qualified health careprofessional; first 30 minutes, face-toface with the patient, familymember(s), and/or surrogate)Advance care planning, including theexplanation and discussion ofadvance directives such as standardforms (with completion of such forms,when performed), by the physician orother qualified health careprofessional; each additional 30minutesYNCategory 2YNAdd-oncodeG0402Initial preventive physicalexamination; face to face visits,services limited to new beneficiaryduring the first 12 months of MedicareenrollmentYNCategory 1G0403Electrocardiogram, routine ECG with12 leads; performed as a screeningfor the initial preventive physicalexamination with interpretation andreportYNCategory 2Page 1Separate Payment Categories:Category 1: Preventive office visitPreventive – Preventive – SeparatelyMedicare? Commercial? Payable?G043899498*Medicare S Code DescriptionDiagnosis CodeLimitsZ00.00 andZ00.01Z00.00 andZ00.01Revisions from last publication are highlighted in yellow.Category 2: Separately payable (modifier may be required)Category 3: Not paid w/ preventive E/M codeCategory 4: Not paid w/ any E/M code

Billing Guideline for Preventive ServicesPreventive Office Visits onMedicare SCode1 per lifetimewithin 12 monthsof MedicareenrollmentMedicare(continued fromabove)CPT/HCPCS Code DescriptionPreventive – Preventive – SeparatelyMedicare? Commercial? Payable?G0404Electrocardiogram, routine ECG with12 leads; tracing only, withoutinterpretation and report, performedas a screening for the initialpreventive physical examYNCategory 2G0405Electrocardiogram, routine ECG with12 leads; interpretation and reportonly, performed as a screening for theinitial preventive physical examYNCategory 2Diagnosis CodeLimitsZ00.00 andZ00.01*CPT codes 99497 and 99498 used to describe advance care planning (ACP) will be separately payable under the MPFS for OPPS claims when billed as part of the AWVon the same date of service by the same provider. ACP services furnished on the same day and by the same provider as an AWV are considered a preventive service.Therefore, beneficiary cost-share is not applied to the codes used to report ACP services when performed as part of an AWV.Preventive Office Visits continuedServiceDescriptionPrenatal andPostnatalOffice equencyLimitsUp to 15prenatal andpostnatalvisits arecovered aspreventiveeach calendaryear.*CPT/HCPCSCode99201CPT/HCPCS Code DescriptionOffice or other outpatient visit for the evaluationand management of a new patient, whichrequires these 3 key components: A problemfocused history; A problem focusedexamination; Straightforward medical decisionmaking. Counseling and/or coordination of carewith other physicians, other qualified healthcare professionals, or agencies are providedconsistent with the nature of the problem(s) andthe patient's and/or family's needs. Usually, thepresenting problem(s) are self-limited or minor.Typically, 10 minutes are spent face-to-facewith the patient and/or family.Page 2Separate Payment Categories:Category 1: Preventive office visitPreventive – Preventive – SeparatelyMedicare? Commercial? Payable?NYCategory 1DiagnosisCode LimitsO09.00 –O9A.53,Z33.1,Z34.00 – Z36,Z39.0 – Z39.2Revisions from last publication are highlighted in yellow.Category 2: Separately payable (modifier may be required)Category 3: Not paid w/ preventive E/M codeCategory 4: Not paid w/ any E/M code

Billing Guideline for Preventive ServicesPreventive Office Visits continuedServiceDescriptionPrenatal andPostnatalOffice Visits(continuedfrom equencyLimitsUp to 15prenatal andpostnatalvisits arecovered aspreventiveeach calendaryear.*CPT/HCPCSCodeCPT/HCPCS Code Description99202Office or other outpatient visit for the evaluationand management of a new patient, whichrequires these 3 key components: Anexpanded problem focused history; Anexpanded problem focused examination;Straightforward medical decision making.Counseling and/or coordination of care withother physicians, other qualified health careprofessionals, or agencies are providedconsistent with the nature of the problem(s) andthe patient's and/or family's needs. Usually, thepresenting problem(s) are of low to moderateseverity. Typically, 20 minutes are spent faceto-face with the patient and/or family.NYCategory 199203Office or other outpatient visit for the evaluationand management of a new patient, whichrequires these 3 key components: A detailedhistory; A detailed examination; Medicaldecision making of low complexity. Counselingand/or coordination of care with otherphysicians, other qualified health careprofessionals, or agencies are providedconsistent with the nature of the problem(s) andthe patient's and/or family's needs. Usually, thepresenting problem(s) are of moderate severity.Typically, 30 minutes are spent face-to-facewith the patient and/or family.NYCategory 1Page 3Separate Payment Categories:Category 1: Preventive office visitPreventive – Preventive – SeparatelyMedicare? Commercial? Payable?DiagnosisCode LimitsO09.00 –O9A.53,Z33.1,Z34.00 – Z36,Z39.0 – Z39.2Revisions from last publication are highlighted in yellow.Category 2: Separately payable (modifier may be required)Category 3: Not paid w/ preventive E/M codeCategory 4: Not paid w/ any E/M code

Billing Guideline for Preventive ServicesPreventive Office Visits continuedServiceDescriptionPrenatal andPostnatalOffice Visits(continuedfrom equencyLimitsUp to 15prenatal andpostnatalvisits arecovered aspreventiveeach calendaryear.*CPT/HCPCSCodeCPT/HCPCS Code Description99204Office or other outpatient visit for the evaluationand management of a new patient, whichrequires these 3 key components: Acomprehensive history; A comprehensiveexamination; Medical decision making ofmoderate complexity. Counseling and/orcoordination of care with other physicians,other qualified health care professionals, oragencies are provided consistent with thenature of the problem(s) and the patient'sand/or family's needs. Usually, the presentingproblem(s) are of moderate to high severity.Typically, 45 minutes are spent face-to-facewith the patient and/or family.NYCategory 199205Office or other outpatient visit for the evaluationand management of a new patient, whichrequires these 3 key components: Acomprehensive history; A comprehensiveexamination; Medical decision making of highcomplexity. Counseling and/or coordination ofcare with other physicians, other qualifiedhealth care professionals, or agencies areprovided consistent with the nature of theproblem(s) and the patient's and/or family'sneeds. Usually, the presenting problem(s) areof moderate to high severity. Typically, 60minutes are spent face-to-face with the patientand/or family.NYCategory 199211Office or other outpatient visit for the evaluationand management of an established patient, thatmay not require the presence of a physician orother qualified health care professional.Usually, the presenting problem(s) are minimal.Typically, 5 minutes are spent performing orsupervising these services.NYCategory 1Page 4Separate Payment Categories:Category 1: Preventive office visitPreventive – Preventive – SeparatelyMedicare? Commercial? Payable?DiagnosisCode LimitsO09.00 –O9A.53,Z33.1,Z34.00 – Z36,Z39.0 – Z39.2Revisions from last publication are highlighted in yellow.Category 2: Separately payable (modifier may be required)Category 3: Not paid w/ preventive E/M codeCategory 4: Not paid w/ any E/M code

Billing Guideline for Preventive ServicesPreventive Office Visits continuedServiceDescriptionPrenatal andPostnatalOffice Visits(continuedfrom equencyLimitsUp to 15prenatal andpostnatalvisits arecovered aspreventiveeach calendaryear.*CPT/HCPCSCodeCPT/HCPCS Code Description99212Office or other outpatient visit for the evaluationand management of an established patient,which requires at least 2 of these 3 keycomponents: A problem focused history; Aproblem focused examination; Straightforwardmedical decision making. Counseling and/orcoordination of care with other physicians,other qualified health care professionals, oragencies are provided consistent with thenature of the problem(s) and the patient'sand/or family's needs. Usually, the presentingproblem(s) are self-limited or minor. Typically,10 minutes are spent face-to-face with thepatient and/or family.NYCategory 199213Office or other outpatient visit for the evaluationand management of an established patient,which requires at least 2 of these 3 keycomponents: An expanded problem focusedhistory; An expanded problem focusedexamination; Medical decision making of lowcomplexity. Counseling and coordination ofcare with other physicians, other qualifiedhealth care professionals, or agencies areprovided consistent with the nature of theproblem(s) and the patient's and/or family'sneeds. Usually, the presenting problem(s) areof low to moderate severity. Typically, 15minutes are spent face-to-face with the patientand/or family.NYCategory 1Page 5Separate Payment Categories:Category 1: Preventive office visitPreventive – Preventive – SeparatelyMedicare? Commercial? Payable?DiagnosisCode LimitsO09.00 –O9A.53,Z33.1,Z34.00 – Z36,Z39.0 – Z39.2Revisions from last publication are highlighted in yellow.Category 2: Separately payable (modifier may be required)Category 3: Not paid w/ preventive E/M codeCategory 4: Not paid w/ any E/M code

Billing Guideline for Preventive ServicesPreventive Office Visits continuedServiceDescriptionPrenatal andPostnatalOffice Visits(continuedfrom equencyLimitsUp to 15prenatal andpostnatalvisits arecovered aspreventiveeach calendaryear.*CPT/HCPCSCPT/HCPCS Code DescriptionCode99214Office or other outpatient visit for the evaluationand management of an established patient,which requires at least 2 of these 3 keycomponents: A detailed history; A detailedexamination; Medical decision making ofmoderate complexity. Counseling and/orcoordination of care with other physicians,other qualified health care professionals, oragencies are provided consistent with thenature of the problem(s) and the patient'sand/or family's needs. Usually, the presentingproblem(s) are of moderate to high severity.Typically, 25 minutes are spent face-to-facewith the patient and/or family.99215Office or other outpatient visit for the evaluationand management of an established patient,which requires at least 2 of these 3 keycomponents: A comprehensive history; Acomprehensive examination; Medical decisionmaking of high complexity. Counseling and/orcoordination of care with other physicians,other qualified health care professionals, oragencies are provided consistent with thenature of the problem(s) and the patient'sand/or family's needs. Usually, the presentingproblem(s) are of moderate to high severity.Typically, 40 minutes are spent face-to-facewith the patient and/or family.59425Antepartum care only; 4-6 visits59426Antepartum care only; 7 or more visits59430Postpartum care only (separate procedure)Preventive – Preventive – SeparatelyMedicare? Commercial? Payable?NYCategory 1NYCategory 1NYCategory 1NYCategory 1NYCategory 1DiagnosisCode LimitsO09.00 –O9A.53,Z33.1,Z34.00 – Z36,Z39.0 – Z39.2*Services rendered by a Perinatologist/Maternal-Fetal Medicine specialist are not covered under the preventive benefit and are subject to cost-sharing. Preventive coveragevaries by plan. See plan documents.Page 6Separate Payment Categories:Category 1: Preventive office visitRevisions from last publication are highlighted in yellow.Category 2: Separately payable (modifier may be required)Category 3: Not paid w/ preventive E/M codeCategory 4: Not paid w/ any E/M code

Billing Guideline for Preventive ServicesPreventive Office Visits continuedServiceDescriptionPreventiveOffice VisitsPopulationAdultsFrequencyLimitsCPT/HCPCS Code DescriptionPreventive – SeparatelyCommercial? Payable?99385Preventive E/M, new patient; 18-39yearsYYCategory 199386Preventive E/M, new patient; 40-64yearsYYCategory 199387Preventive E/M, new patient; 65 yearsYYCategory 1Commercial:1 per calendaryear99395Preventive E/M, established patient;18-39 yearsYYCategory 199396Preventive E/M, established patient;40-64 yearsYYCategory 199397Preventive E/M, established patient;65 yearsYYCategory 199381Preventive E/M, new patient; infant(age younger than 1 year)YYCategory 199391Preventive E/M, established patient;infant (age younger than 1 year)YYCategory 1Up to 7 visits forchildren 1 – 4years of age99382Preventive E/M, new patient; earlychildhood (1-4 years)YYCategory 199392Preventive E/M, established patient;early childhood (1-4 years)YYCategory 11 per calendaryear for children5 – 11 years ofage99383Preventive E/M, new patient; latechildhood (5-11 years)YYCategory 199393Preventive E/M; late childhood (5-11years)YYCategory 1Up to 7 visits forchildren under 1year of agePage 7Separate Payment Categories:Category 1: Preventive office visitPreventive –Medicare?1 per calendaryear for allmembers, aswell as wellwoman examsfor females asfollows:Medicare:High-risk: 1 percalendar yearNormal risk: 1every 24 monthsChildren andAdolescentsCPT/HCPCSCodeDiagnosis CodeLimitsAnnual Physical:Z00.00, Z00.01Well-woman:Z01.411, Z76.1, Z76.2Well-Child:Z00.121,Z00.129, Z76.1,Z76.2Revisions from last publication are highlighted in yellow.Category 2: Separately payable (modifier may be required)Category 3: Not paid w/ preventive E/M codeCategory 4: Not paid w/ any E/M code

Billing Guideline for Preventive ServicesPreventive Office Visits continuedServiceDescriptionPreventiveOffice VisitsPopulationChildren andAdolescents(continued fromabove)FrequencyLimits1 per calendaryear for allmembers, aswell as 1 wellwoman exam percalendar year forfemale members.CPT/HCPCSCodeCPT/HCPCS Code DescriptionPreventive –Medicare?Preventive – SeparatelyCommercial? Payable?Diagnosis CodeLimits99384Preventive E/M, new patient;adolescent (12-17 years)YYCategory 1Well-Child:Z00.121,Z00.129,Z76.1, Z76.299394Preventive E/M, established patient;adolescent (12-17 years)YYCategory 1Well-Woman:Z01.411, Z01.419Behavioral/Developmental eningPopulationFrequencyLimitsAdults andAdolescents1 per calendaryearCPT/HCPCSCodeCPT/HCPCS Code DescriptionPreventive – Preventive – SeparatelyMedicare? Commercial? Payable?Diagnosis CodeLimits99408Alcohol and/or substance abuse(other than tobacco) abuse structuredscreening (et, AUDIT, DAST), andbrief intervention (SBI) services; 15 30 minutesYYCategory 2UnlimitedG0442Annual alcohol screen 15 minYYCategory 2UnlimitedDepressionScreeningAdults andAdolescents1 per calendaryearG0444Annual Depression Screening, 15minutesYYCategory d inE/M codeN/ANNN/AN/A1 per calendaryear96110Developmental testing; limited (eg,Developmental Screening Test II,Early Language Milestone Screen),with interpretation and reportNYCategory 2UnlimitedPage 8Separate Payment Categories:Category 1: Preventive office visitRevisions from last publication are highlighted in yellow.Category 2: Separately payable (modifier may be required)Category 3: Not paid w/ preventive E/M codeCategory 4: Not paid w/ any E/M code

Billing Guideline for Preventive ServicesBehavioral/Developmental Screenings opulationChildrenFrequencyLimits1 per calendaryearCPT/HCPCSCodeAdults andChildren1 per calendaryearPreventive –Medicare?Preventive – SeparatelyCommercial? Payable?Diagnosis CodeLimits96127Brief emotional/behavioralassessment (eg, depressioninventory, attentiondeficit/hyperactivity disorder (ADHD)scale, with scoring anddocumentation, per standardizedinstrument.NYCategory 2UnlimitedG0451Development testing, withinterpretation and report perstandardized instrument formNYCategory 2UnlimitedIncluded inE/M CodeN/AYYN/AUnlimited(continued fromabove)ObesityScreeningCPT/HCPCS Code DescriptionBehavioral selingBreast CancerPreventionFrequencyLimitsAdults andAdolescents1 per calendaryear99409Alcohol and/or substance abuse(other than tobacco) abuse structuredscreening (et, AUDIT, DAST), andbrief intervention (SBI) services;greater than 30 minutesYYCategory 2UnlimitedUp to 4 timesper yearG0443Brief face-to-face behavioralcounseling for Alcohol Misuse, 15minutesYYCategory 3UnlimitedN/AIncluded inE/M CodeN/AYYN/AN/AFemalesCPT/HCPCSCodePreventive – Preventive – SeparatelyMedicare? Commercial? Payable?PopulationCPT/HCPCS Code DescriptionPage 9Separate Payment Categories:Category 1: Preventive office visitDiagnosis CodeLimitsRevisions from last publication are highlighted in yellow.Category 2: Separately payable (modifier may be required)Category 3: Not paid w/ preventive E/M codeCategory 4: Not paid w/ any E/M code

Billing Guideline for Preventive ServicesBehavioral Counseling rDisease(includingaspirin use)AdultsDiabetes SelfManagementTrainingServices (DSMT)AdultsFrequencyLimitsAdultsCPT/HCPCS Code DescriptionDiagnosis CodeLimitsIncluded inE/M CodeN/AYYN/AN/AOnce percalendar yearG0446Annual face-to-face intensivebehavioral therapy to reducecardiovascular disease risk;individual, 15 minutesYNCategory 2Unlimited(Medicare only)10 hours firstyear; 2 hourssubsequentyearsG0108Diabetes outpatient self-managementtraining services, individual, per 30minutesYYCategory 2UnlimitedG0109Diabetes outpatient self-managementtraining services, group session (2 ormore), per 30 minutesYYCategory 2Unlimited97802Medical nutrition therapy; initialassessment and intervention,individual, face-to-face with thepatient, each 15 minutesYYCategory 297803Medical nutrition therapy; reassessment and intervention,individual, face-to-face with thepatient, each 15 minutesYYCategory 297804Medical nutrition therapy; group (2 ormore individual(s)), each 30 minutesYYCategory 2G0270Medical nutrition therapy;reassessment and subsequentintervention(s) following secondreferral in same year for change indiagnosis, medical condition ortreatment regimenYYCategory 2Up to 3 hoursper calendaryear(Benefits mayvary by plan.)P a g e 10Separate Payment Categories:Category 1: Preventive office visitPreventive – Preventive – SeparatelyMedicare? Commercial? Payable?N/A(Benefits mayvary by plan.)Diet/NutritionCPT/HCPCSCodeLimited totreatment forcardiovascular ordiet‐relatedchronic diseasesthat arediagnosed by aphysician,including, but notlimited to:1. Diabetes2. Heart Disease3. KidneyDisease4. Lipid Disorders5. Malnutrition6. ObesityDx codes notspecified.Revisions from last publication are highlighted in yellow.Category 2: Separately payable (modifier may be required)Category 3: Not paid w/ preventive E/M codeCategory 4: Not paid w/ any E/M code

Billing Guideline for Preventive ServicesBehavioral Counseling nAdults(continued fromabove)FrequencyLimitsUp to 3 hoursper calendaryearCPT/HCPCSCodeCPT/HCPCS Code DescriptionPreventive – Preventive – SeparatelyMedicare? Commercial? Payable?Diagnosis CodeLimitsG0271Medical nutrition therapy,reassessment and subsequentintervention(s) following secondreferral in same year for change indiagnosis, medical condition, ortreatment regimen (includingadditional hours needed for renaldisease), groupYYCategory 2See above.(Benefits mayvary by plan.)Folic AcidSupplementationPregnantindividualsN/AIncluded inE/M CodeN/AYYN/AN/AGeneticCounseling:BRCA for BreastCancerFemalesUp to 4 visitsper calendaryear96040Medical genetics and geneticcounseling services, each 30 minutesface-to-face with patient/familyYYCategory 2Z15.01, Z15.02S0265Genetic counseling, under physiciansupervision, each 15 minutesYYCategory 2Interpersonaland DomesticViolenceFemalesAs neededIncluded inE/M alsAs neededIncluded inE/M CodeN/AYYN/AN/AObesityCounselingIndividuals 6years of ageor olderMedicare22 visits percalendar yearG0447Face-to-face behavioral counselingfor obesity, individual, 15 minutesYYCategory 3Z68.30 - Z68.45Commercial26 visits percalendar yearG0473Face-to-face behavioral counselingfor obesity, group (2-10), 30 minutesYYCategory 3P a g e 11Separate Payment Categories:Category 1: Preventive office visitRevisions from last publication are highlighted in yellow.Category 2: Separately payable (modifier may be required)Category 3: Not paid w/ preventive E/M codeCategory 4: Not paid w/ any E/M code

Billing Guideline for Preventive ServicesBehavioral Counseling nued fromabove)PopulationFrequencyLimitsIndividuals 6years of ageor olderCommercial26 visits percalendar yearCPT/HCPCSCodeCPT/HCPCS Code Description99401Preventive medicine counselingand/or risk factor reductionintervention(s) provided to anindividual (separate procedure);approximately 15 minutesNYCategory 299402Preventive medicine counselingand/or risk factor reductionintervention(s) provided to anindividual (separate procedure);approximately 30 minutesNYCategory 299403Preventive medicine counselingand/or risk factor reductionintervention(s) provided to anindividual (separate procedure);approximately 45 minutesNYCategory 299404Preventive medicine counselingand/or risk factor reductionintervention(s) provided to anindividual (separate procedure);approximately 60 minutesNYCategory 299411Preventive medicine counselingand/or risk factor reductionintervention(s) provided to individualsin a group setting (separateprocedure); approximately 30 minutesNYCategory 299412Preventive medicine counselingand/or risk factor reductionintervention(s) provided to individualsin a group setting (separateprocedure); approximately 60 minutesNYCategory 2P a g e 12Separate Payment Categories:Category 1: Preventive office visitPreventive – Preventive – SeparatelyMedicare? Commercial? Payable?Diagnosis CodeLimitsZ68.30 - Z68.45Revisions from last publication are highlighted in yellow.Category 2: Separately payable (modifier may be required)Category 3: Not paid w/ preventive E/M codeCategory 4: Not paid w/ any E/M code

Billing Guideline for Preventive ServicesBehavioral Counseling tsCPT/HCPCSCodeCPT/HCPCS Code DescriptionPreventive – Preventive – SeparatelyMedicare? Commercial? Payable?Diagnosis CodeLimitsOral Health –ChildrenChildrenN/A99188Application of topical fluoride varnishby a physician or other qualifiedhealth care professionalYYCategory 2UnlimitedSexuallyTransmittedInfections (STIs)Adults andAdolescentsUnlimited99401Preventive medicine counselingand/or risk factor reductionintervention(s) provided to anindividual (separate procedure);approximately 15 minutesNYCategory 2Z70.0, Z70.1,Z70.3, Z70.8,Z70.9, Z72.51Z72.53, andZ72.8999402Preventive medicine counselingand/or risk factor reductionintervention(s) provided to anindividual (separate procedure);approximately 30 minutesNYCategory 299403Preventive medicine counselingand/or risk factor reductionintervention(s) provided to anindividual (separate procedure);approximately 45 minutesNYCategory 299404Preventive medicine counselingand/or risk factor reductionintervention(s) provided to anindividual (

Billing Guideline for Preventive Services P a g e 2 Revisions from last publication are highlighted in yellow. Separate Payment Categories: Category 1: Preventive office visit Category 2: Separately payable (modifier may be required) Category 3: Not paid w/ preventive E/M code Category 4: No

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