Health Care Reform Preventive Services Coding Guide
Health Care Reform Preventive Services Coding GuideThe Patient Protection and Affordable Care Act (PPACA) and the Health Care and Education Reconciliation Act of 2010 (HCERA) has designated the services listed belowas preventive benefits and available with no cost-sharing when provided by an in-network provider for members of non-grandfathered health plans. In addition to the serviceslisted below, your patient may have additional preventive care benefits covered under their health plan that may or may not be covered at 100%. Your patient should checktheir benefit booklet for details on these additional preventive care benefits. The following tables provide a quick reference guide for submitting claims for preventive serviceswith a “well-person” diagnosis code as the primary (first) diagnosis on the claim. This information is intended as a reference tool for your convenience and is not a guaranteeof payment. This guide is subject to change based on new or revised laws and/or regulations, additional guidance and/or BCBSNC medical policy.IMPORTANT INFORMATION: Services must be billed with the appropriate diagnosis, at the line level of the claim (Block 24E), pursuant to industry standard codingguidelines. Preventive or screening services are intended for those who currently exhibit no signs or symptoms of disease. Services otherwise deemed preventive that are received inan inpatient setting, an emergency room, or that include additional procedures or diagnostic services may be subject to copayment, deductible and coinsurance. Submittingscreening service codes (CPT, HCPCs, ICD-9 or ICD-10) when signs or symptoms are present constitutes inappropriate coding which could result in recoupment of monies paid to the providerfor those services. Additionally, these services are subject to certain limitations depending on medical necessity and other reasonable medical management techniques. If youhave questions, please contact the Provider Blue Line at 1-800-214-4844.Grade A and BRecommendations of U.S.Preventive Services TaskForce (USPSTF) currentlyeffective unless otherwisenoted1.Screening for Abdominal AorticAneurysm(one time screening for abdominal aorticaneurysm by ultrasonography in men ages65-75 who have ever smoked)2.Screening and counseling to reducealcohol misuse The USPSTF recommendsthat clinicians screen adults aged 18 yearsor older for alcohol misuse and providepersons engaged in risky or hazardousdrinking with brief behavioral counselinginterventions to reduce alcohol misuse.Aspirin to prevent cardiovascular diseaseand colorectal cancer in men and women(Low-dose aspirin use for the primaryprevention of cardiovascular disease (CVD)and colorectal cancer (CRC) in adults aged50 to 59 years who have a 10% or greater10-year CVD risk, are not at increased riskfor bleeding, have a life expectancy of atleast 10 years, and are willing to take lowdose aspirin daily for at least 10 years.)4.Screening for bacteriuria (screening forasymptomatic bacteriuria with urine culturefor pregnant women at 12 - 16 weeks'gestation or at the first prenatal visit, if later)CPT or HCPCSG0389Effective1/1/2017:76706ICD-10 DiagnosisZ13.6Comments99408, 99409,G0442 or G0443,G0396, G0397Z13.89, F10.10, F10.120, F10.129These codes are to be used in the absence of a wellnessvisit.Not applicable,administered throughPharmacyNot applicable, administered through PharmacyOTC Aspirin (81 mg) is dispensed to member with aphysician order with no cost-sharing.87081, 87084,87086 or 87088Z34.00, Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82,Z34.83, Z34.90, Z34.91, Z34.92, Z34.93, Z33.1, O09.00,O09.01, O09.02, O09.03, O09.10, O09.11, O09.12,O09.13, O09.291, O09.292,O09.293, O09.299, O09.40,O09.41, O09.42, O09.43, O09.211, O09.212,O09.213,O09.219, O09.30, O09.31, O09.32, O09.33, O09.511,O09.512,O09.513, O09.519, O09.521 O09.522,O09.523,O09.529,O09.611, O09.612,O09.613, O09.619,O09.621,O09.622,O09.623, O09.629,O09.811, .829,O36.80X0,O36.80X1,O36.80X2, O36.80X3,O36.80X4,O36.80X5,O36.80X9, O09.891, O09.892, O09.893,O09.899, O09.70, O09.71, O09.72, O09.73, O09.90,O09.91, O09.92, O09.93O09.A0, O09.A1, O09.A2, O09.A3Z13.6 or other wellness exam diagnosis codeFor coverage of ABPM or HBPM diagnosis code R03.0 isrequiredDipstick or other urinalysis included in global maternityvisits. Only urine culture part of preventive servicesmandate.NOTE: Z33.1 is not an acceptable principlediagnosis code.5.Screening for high blood pressure(Recommends screening for high bloodpressure in adults aged 18 years or older.The USPSTF recommends obtainingmeasurements outside of the clinical settingfor diagnostic confirmation before startingtreatment)99385-99387 or99395-99397For ambulatoryblood pressuremonitoring use93784, 93786,93788, 93790For home bloodpressure monitoruse A46706.Counseling related to BRCA screening(Recommends that primary care providersscreen women who have family memberswith breast, ovarian, tubal, or peritonealcancer with 1 of several screening toolsdesigned to identify a family history that maybe associated with an increased risk forpotentially harmful mutations in breastcancer susceptibility genes (BRCA 1 orBRCA 2). Women with positive screeningresults should receive generic counselingand, if indicated after counseling, BRCAtesting.)Referrals forcounseling includedin wellness visitcodes 99385-99387,99395-99397Counseling servicesuse 96040, 99401,99402, 99403,99404, or S0265Genetic testing use81211, 81212,81213, 81214,81215, 81216,81217 or 81162Z80.3, Z80.41, Z85.07, Z85.3, Z85.43, Z85.44, Z85.46, orZ31.5, Z71.83 (effective 10/1/17)An Independent licensee of the Blue Cross and Blue Shield Association. January 1, 2018Part of wellness office visit.Effective 1/1/2017, ambulatory blood pressuremonitoring(ABPM) or home blood pressure monitors(HBPM) for confirmation of high blood pressure iscovered at 100%. Home blood pressure monitors mustbe purchased from an in-network durable medicalequipment (DME) vendor.Services for BRCA 1/BRCA 2 testing will be providedwith no cost sharing to appropriate groups when themedical policy criteria are met.See BCBSNC Medical Policy: Genetic Testing for Breastand Ovarian Cancer99401-99404 are to be used in the absence of a wellnessvisit.
Health Care Reform Preventive Services Coding GuideGrade A and BRecommendations of U.S.Preventive Services TaskForce (USPSTF) currentlyeffective unless otherwisenoted7.Screening for breast cancer[mammography](for women aged 40 or over every 1-2 yrs ,with or without clinical breast examination)8.Chemoprevention of breast cancer(Recommends that clinicians engage inshared, informed decision making withwomen who are at increased risk for breastcancer about medications to reduce theirrisk. For women who are at increased riskfor breast cancer and at low risk for adversemedication effects, clinicians should offer toprescribe risk-reducing medications, such astamoxifen or raloxifene)CPT or HCPCSG0202, 7706399401-99402 or isincluded in wellnessvisit 99385-99387,99395-99397ICD-10 DiagnosisZ12.31, Z12.39CommentsIf the patient has had an abnormal mammogram in thepast, subsequent routine mammograms may be codedas diagnostic: 77061, 77062, 77065, 77066, G0279 witha diagnosis reflective of the abnormality.Z15.01, Z80.3, D24.1, D24.2, D24.9, N60.81, N60.82,N60.89This recommendation applies to asymptomatic womenaged 35 years or older without a prior diagnosis of breastcancer, ductal carcinoma in situ, or lobular carcinoma insitu. Generic risk-reducing medications are dispensed tomember with a physician order with no cost-sharing.For members who have swallowing problems or mayhave an intolerance to generic products, brand productsmay also be made available by completing the CopayWaiver Form and faxing it to the number on the bottomof the document.99401-99404 are to be used in the absence of a wellnessvisit.NOTE: Z15.01 is not an acceptable principle diagnosis9.Interventions to support breast feeding(interventions during pregnancy and afterbirth to promote and support breastfeeding)99401-99403 or partof other office visitO30.93, Z34.03, Z34.83, Z34.93, Z39.199401-99403 are to be used in the absence of a wellnessvisit.10.Screening for cervical cancer(in women ages 21 to 65 yrs with cytology(pap smear) every 3 yrs or, for women ages30-65 yrs who want to lengthen thescreening interval, screening with acombination of cytology and humanpapillomavirus (HPV) testing every 5 yrs)88141, 88142,88143, 88147,88148, 88150,88152, 88153,88154, 88164,88165, 88166,88167, 88174,88175, 87623,87624, 87625,G0101, G0123,G0124, G0141,G0143, G0144,G0145, G0147,G0148, P3000,P3001Z00.00, Z00.01, Z01.411, Z01.419, Z01.42, Z12.4, Z11.51This recommendation does not apply to women whohave received a diagnosis of a high-grade precancerouscervical lesion or cervical cancer, women with in uteroexposure to diethylstilbestrol, or women who areimmunocompromised (such as those who are HIVpositive).11.Screening for chlamydial infection innon-pregnant and pregnant women (forall sexually active non-pregnant andpregnant young women ages 24 andyounger and for older, non-pregnant andpregnant women who are at increased risk)87270, 87320,87490, 87491 and87810NOTE: Z33.1 is not an acceptable principle diagnosiscode.12.Screening for cholesterolabnormalities:*men35 and older (for lipid disorders)*men younger than 35 (for ages 20-35 forlipid disorders if they are at increased risk forcoronary heart disease)*women 20 and older (for lipid disorders ifthey are at increased risk for coronary heartdisease)See also: Statin Use for the PrimaryPrevention of Cardiovascular Disease inAdults80061, 82465 or83718Z34.00, Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82,Z34.83, Z34.90, Z34.91, Z34.92, Z34.93, Z33.1, O09.00,O09.01, O09.02, O09.03, O09.10, O09.11, O09.12,O09.13, O09.291, O09.292, O09.293, O09.299, O09.40,O09.41, O09.42, O09.43, O09.211, O09.212, O09.213,O09.219, O09.30, O09.31, O09.32, O09.33, O09.511,O09.512, O09.513, O09.519, O09.521 O09.522, O09.523,O09.529, O09.611, O09.612, O09.613, O09.619,O09.621, O09.622, O09.623, O09.629, O09.811,O09.812, O09.813, O09.819, O09.821, O09.822,O09.823, O09.829, O36.80X0, O36.80X1, O36.80X2,O36.80X3, O36.80X4, O36.80X5, O36.80X9, O09.891,O09.892, O09.893, O09.899, O09.70, O09.71, O09.72,O09.73, O09.90, O09.91, O09.92, O09.93, Z11.8,O09.A0, O09.A1, O09.A2, O09.A3Z13.220An Independent licensee of the Blue Cross and Blue Shield Association. January 1, 2018Do not bill the panel lab code in addition to separate testsincluded in the panel.
Health Care Reform Preventive Services Coding GuideGrade A and BRecommendations of U.S.Preventive Services TaskForce (USPSTF) currentlyeffective unless otherwisenoted13.Prevention of dental caries(recommends that primary care cliniciansprescribe oral fluoride supplementationstarting at age 6 months up to age 16 forchildren whose water supply is deficient influoride. Also recommends that primarycare clinicians apply fluoride varnish to theprimary teeth of all infants and childrenstarting at the age of primary tooth eruption.)14, 15.Screening for colorectal cancer(using fecal occult blood testing,sigmoidoscopy, or colonoscopy, in adultsbeginning at ages 50-75)CPT or HCPCS99188, 99401 or99402May prescribe oralfluoride during childwellness visit:99381-99382 or99391-99392 withappropriate wellnessdiagnosisICD-10 DiagnosisZ29.3Fecal occult bloodtesting:82270, 82274 orG0328Sigmoidoscopy:45330, 45333,45334, 45338,G0104 , G6022,88305 andEffective 1/1/2017G0500Colonoscopy:45378, 45380,45381, 45382,45384, 45385,74263, G0105,G0121, G6024,00810,00812,88305 andG0500Screening Procedures:Z12.11, Z12.12, K51.40, K62.1, K63.5, D12.0, D12.2,D12.3, D12.4, D12.5, D12.6, D12.7, D12.8, or D12.9Pathology services (88305):Z12.11, Z12.12, K51.40, K62.1, K63.5, D12.0, D12.2,D12.3, D12.4, D12.5, D12.6, D12.7, D12.8, or D12.9Visit or Consultations:Z01.818Consultation oroffice visit prior toscreeningcolonoscopy:S028516.Screening for depression:*adults (screening for depression, includingpregnant and postpartum women, whenstaff-assisted depression care supports arein place to assure accurate diagnosis,effective treatment, and follow-up)*adolescents (screening 12-18 yr olds formajor depressive disorder when systems arein place to ensure accurate diagnosis,psychotherapy [cognitive-behavioral orinterpersonal], and follow-up)G0444 or preventivevisitZ13.89An Independent licensee of the Blue Cross and Blue Shield Association. January 1, 2018CommentsFluoride varnish will not be covered beyond the 5thbirthday.Oral fluoride supplementation will be covered from ages6 months through 16 years.BCBSNC recommends counseling/education in additionto varnish application. For well child visit: Any counseling services received atthe time of a well child visit are considered part of thepreventive visit and are not reimbursed separately. For sick visit: If the varnish is applied during a visitother than for wellness, providers should referencediagnosis code Z41.8 or Z29.3 as the primary diagnosisfor the line item of the varnish application service, 99188,on the claim in order to process correctly. Ifeducation/counseling on prevention and risk factorreduction of dental caries is conducted during a sick visit,providers should again reference diagnosis code Z41.8or Z29.3 as the primary diagnosis for the line item of thecounseling service, 99401/99402, on the claim in order toprocess correctly.BCBSNC will disallow D codes if submitted by nonlicensed dental providers99401-99404 are to be used in the absence of a wellnessvisit.Colorectal cancer screening mandate does not includebarium enema or fecal DNA.***If a test is performed for screening purposes,screening service codes may be submitted even in theevent of positive findings e.g., polyp found during ascreening colonoscopy. It is critical to use a screeningdiagnosis as the primary diagnosis for the claim line ofthe test performed [not just in the header diagnoses].Any abnormal findings from a screening test should belisted as a secondary diagnosis code. Failure to listscreening as the primary diagnosis code will affectcorrect claim adjudication.When billing for a visit or consultation prior to a screeningcolonoscopy, S0285 should be submitted with theappropriate diagnosis code.As of 9/1/2016, Certain bowel preparation medications,when medically appropriate and prescribed by a healthcare provider are allowed without cost sharing whendispensed at a participating pharmacy. If there is amedical reason a member cannot take a generic bowelpreparation, the physician should review the clinicalcriteria and if appropriate, submit fax form.As of 1/1/2017, Moderate sedation (G0500) performedby the physician performing the procedure is allowed butcannot be billed on the same DOS as 00810, 00812.Part of any problem or preventive office visit.
Health Care Reform Preventive Services Coding GuideGrade A and BRecommendations of U.S.Preventive Services TaskForce (USPSTF) currentlyeffective unless otherwisenoted17.Screening for diabetes Screening forabnormal blood glucose as part ofcardiovascular risk assessment. Cliniciansshould offer or refer patients with abnormalblood glucose to intensive behavioralcounseling interventions to promote ahealthful diet and physical activity.Adults aged 40 to 70 who are overweight orobese18.Behavioral Counseling to promote ahealthful diet and physical activity forcardiovascular disease prevention inadults with cardiovascular risk factors(Recommends offering or referring adultswho are overweight or obese and haveadditional cardiovascular disease (CVD) riskfactors to intensive behavioral counselinginterventions to promote a healthful diet andphysical activity for CVD prevention.)19. Fall Prevention (Exercise or physicaltherapy and vitamin D supplementation toprevent falls in community-dwelling adultsaged 65 yrs and older who are at increasedrisk for falls.)Supplementation with folic acid(for all women planning or capable ofpregnancy to take a daily supplementcontaining 0.4 - 0.8 mg [400-600 mcg] offolic acid)CPT or HCPCS82947 or 83036ICD-10 DiagnosisZ13.1Comments99402, 99403,99404, 97802,97803, 97804,S9452, S9470,G0270, G0271,G0108, G0109,S9140, S9141,S9455, S9460,S9465, G0446 orpart of preventivevisitZ71.399401-99404 are to be used in the absence of a wellnessvisit.97001-97002,97110, 97112,97116, 97530,G0151, G0157,G0159, S9131 andS9476.Not applicable,administered throughPharmacyZ91.81Vitamin D is dispensed to member with a physician orderwith no cost-sharing.Not applicable, administered through PharmacyOTC folic acid supplements are dispensed to memberwith a physician order with no cost-sharing.In pregnant women between 24 and 28 weeks ofgestation and at the first prenatal visit for pregnantwomen identified to be at high risk for diabetesNOTE: Z33.1 is not an acceptable principlediagnosis code.21. Screening for Gestational DiabetesMellitus(Recommends screening for gestationaldiabetes mellitus (GDM) in asymptomaticpregnant women after 24 weeks ofgestation.)82950Z34.00, Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82,Z34.83, Z34.90, Z34.91, Z34.92, Z34.93, Z33.1, O09.00,O09.01, O09.02, O09.03, O09.10, O09.11, O09.12,O09.13, O09.291, O09.292, O09.293, O09.299, O09.40,O09.41, O09.42, O09.43, O09.211, O09.212, O09.213,O09.219, O09.30, O09.31, O09.32, O09.33, O09.511,O09.512, O09.513, O09.519, O09.521 O09.522, O09.523,O09.529, O09.611, O09.612, O09.613, O09.619,O09.621, O09.622, O09.623, O09.629, O09.811,O09.812, O09.813, O09.819, O09.821, O09.822,O09.823, O09.829, O36.80X0, O36.80X1, O36.80X2,O36.80X3, O36.80X4, O36.80X5, O36.80X9, O09.891,O09.892, O09.893, O09.899, O09.70, O09.71, O09.72,O09.73, O09.90, O09.91, O09.92, O09.93O09.A0, O09.A1, O09.A2, O09.A322. Screening for gonorrhea for women(all sexually active women, including thosewho are pregnant if they are at increasedrisk for infection [if they are young or haveother individual or population risk factors])87590-87591 and87850Z11.59, Z11.3, Z34.00, Z34.01, Z34.02, Z34.03, Z34.80,Z34.81, Z34.82, Z34.83, Z34.90, Z34.91, Z34.92, Z34.93,Z33.1, O09.00, O09.01, O09.02, O09.03, O09.10, O09.11,O09.12, O09.13, O09.291, O09.292, O09.293, O09.299,O09.40, O09.41, O09.42, O09.43, O09.211, O09.212,O09.213, O09.219, O09.30, O09.31, O09.32, O09.33,O09.511, O09.512, O09.513, O09.519, O09.521 O09.522,O09.523, O09.529, O09.611, O09.612, O09.613,O09.619, O09.621, O09.622, O09.623, O09.629,O09.811, O09.812, O09.813, O09.819, O09.821,O09.822, O09.823, O09.829, O36.80X0, O36.80X1,O36.80X2, O36.80X3, O36.80X4, O36.80X5, O36.80X9,O09.891, O09.892, O09.893, O09.899, O09.70, O09.71,O09.72, O09.73, O09.90, O09.91, O09.92, O09.93, Z11.8O09.A0, O09.A1, O09.A2, O09.A3Prophylactic medication for gonorrhea:newborns (ocular topical medication for allnewborns against gonococcal ophthalmianeonatorum)Not applicable,administered throughFacilityNot applicable, administered through FacilityThis medication is generally administered to newborn atbirth facility.24.Screening for hearing loss(in all newborn infants)92558, 99381,99391 or 92586Z00.121, Z00.129, Z00.110, Z00.111, Z01.10, Z01.118Service is typically performed in the birth facility or aspart of a wellness office visit in the event of a home birth.CPT code 92586 cannot be billed by professionalprovider in a facility setting25.Screening for hemoglobinopathies(for sickle cell disease in newborns)83020, 83021,85660 and S3620Z13.0Service is typically performed in the birth facility or aspart of a wellness office visit in the event of a home birth.An Independent licensee of the Blue Cross and Blue Shield Association. January 1, 2018NOTE: Z33.1 is not an acceptable principlediagnosis code.
Health Care Reform Preventive Services Coding GuideGrade A and BRecommendations of U.S.Preventive Services TaskForce (USPSTF) currentlyeffective unless otherwisenoted26.Screening for Hepatitis B(in pregnant women at first prenatal visit a
Health Care Reform Preventive Services Coding Guide An Independent licensee of the Blue Cross and Blue Shield Association. January 1, 2018 . The Patient Protection and Affordable Care Act (PPACA) and the Health Care and Education Reconciliation Act of 2010 (HCERA) has designated the services listed below
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Preventive care guidelines for children.2 Recommended preventive care services for children will vary based on age and may include some of the following: Age-appropriate well-child examination. . 1 Under the Patient Protection and Affordable Care Act (PPACA), many plans are required to cover certain preventive services without cost share .
Covered “Eligible Preventive Care” also includes preventative care identified by the Department of Health and Human Services under the PPACA. Eligible Preventive Care is covered at 100% when the Member meets age and frequency requirements. The Preventive benefit can be applied to el
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That Put You At Risk. Learn about the four habits that can put you . at risk for tooth decay. See Page 3. Diagnostic and Preventive Services Provided By the TRICARE Dental . Program. Discover covered services and cost shares for Diagnostic and Preventive services rendered under the TDP. See. Page 7. The Key To Preventive Dental Health? You!
The percentage of respondents' engagement in preventive behaviors was calculated by 3 mo separately and overall. Overall, engagement in preventive behaviors was relatively acceptable and more than 45% of participants always carried out all preventive behaviors (Table 2). Engagement in some preventive behaviors, such as wearing a face mask in .
Preventive Care Services Page 3 of 52 UnitedHealthcare Oxford Clinical Policy Effective 06/01/2018 1996-2018, Oxford Health Plans, LLC Non-grandfathered plans are required to cover the preventive care serv
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