Billing Guideline. Subject: Preventive Services. Effective: 1/1/13 Last revision effective: 4/1/16
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1 Subject: Preventive Services Billing Guideline Effective: 1/1/13 Last revision effective: 4/1/16 Background: We are committed to the wellness of our members, and encourage preventive services that can detect serious medical issues early. Certain preventive services are covered at no cost to the member due to plan provisions or regulatory requirements - these services are addressed here. For all lines of business, procedure codes recognized to report preventive services are listed, along with any frequency limits, diagnosis coding, or separate payment policies. Note that preventive screenings are conducted when signs or symptoms of a condition are not present, and in accordance with established guidelines. Testing done diagnostic purposes may be covered with cost-share. Be sure to verify benefits. References: The Afdable Care Act (ACA) requires full coverage of the following preventive services nongrandfathered* plans: Services recommended by the U.S. Preventive Services Task Force (USPSTF) with a rating of A or B. Immunizations recommended by the Advisory Committee on Immunization Practices of the Centers Disease Control and Prevention (CDC) routine use in children, adolescents, and adults. Preventive care and screenings women, infants, children, and adolescents that are provided in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA). We continually monitor changes to preventive service guidelines, and will adjust coverage as required by law. For an official current list of recommended preventive services, visit has adopted many, but not all, of these recommendations. Any differences in coverage and billing rules are noted. For details about Original coverage of preventive services, see The Guide to Preventive Services, Fourth Edition, available at * A grandfathered plan is not required to implement preventive services provisions of the ACA. Contact us to verify benefits if you have questions. Tips: 1) 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 preventive benefit. a. A problem-oriented E/M code will be denied if submitted with a primay preventive diagnosis code. b. A preventive E/M code will be denied if submitted with a primary problem-oriented diagnosis code. 2) Preventive and problem-oriented E/M codes billed together: Preventive E/M codes include a comprehensive exam, encompassing management of chronic and/or stable conditions, abnormal findings on review of systems, and diagnosis and treatment of minor conditions. It is rare 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 the problem 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 a different code is billed. Be sure to use the appropriate primary diagnosis code each service reported on a claim. a. If a test not clearly described as a screening exam is billed with a diagnosis code not listed 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 may be denied. a. If a test not clearly described as a screening exam is billed more often than indicated in this guideline, it may be covered as a diagnostic test with applicable cost-share.
2 Billing Guideline Preventive Services Index Category Service Page Number Preventive Office Visits Annual Wellness Visit () 1 Initial Preventive Physical Exam () 1 Preventive Office Visits 1 Behavioral/Developmental Screenings Alcohol/Drug Misuse 2 Depression 2 Developmental Screening Children 2 Obesity 2 Behavioral Counseling Alcohol/Drug Misuse 2 Breast Cancer Preventive Medication 2 Cardiovascular Disease (including use of aspirin) 2 Diabetes Self Management Training Services (DSMT) 3 Diet/Nutrition 3 Folic Acid Supplementation 3 Genetic Testing BRCA Breast Cancer 3 Interpersonal and Domestic Violence 3 Iron Supplementation 3 Obesity 3 Oral Health Children 3 Sexually Transmitted Infections (STI) 4 Tobacco Use 4 Cancer Screenings Breast 4 5 Cervical 5 7 Colorectal 8 9 Lung 10 Prostate 10 Lab Tests Anemia 10 Bacteriuria 10 BRCA Analysis 11 Chlamydia 12 Cholesterol 12 Diabetes 12 General Health Panels 12 Gonorrhea 12 Hemoglobinopathies (Sickle Cell) 12 Hepatitis B 12 Hepatitis C 12 Herpes 12 HIV 13 HPV DNA 14 Hypothyroidism 14 Lead 14 Obstetric Screening Panel 14 PKU 14 RH Incompatibility 14 Syphilis 14 Other Screenings Abdominal Aortic Aneurism 14 Bone Density (Osteoporosis) 14 Glaucoma 15 Hearing 15 Tuberculin Test 15 Vision 15 Other Women s Health Breastfeeding Services/Supplies 15 Contraception 16 17
3 Billing Guideline Preventive Services Preventive Office Visits Service Description Population Frequency CPT/HCPCS Annual Wellness Visit (AWV) Initial Preventive Physical Examination (IPPE) Preventive Office Visits Members Adults Children Pregnant Women CPT/HCPCS Description Diagnosis Once in a calendar year after the IPPE G0438 Annual wellness visit, including PPPS, first visit N Category 1 Unlimited ( only) Once per calendar year G0439 Annual wellness visit, including PPPS, subsequent visit N Category 1 Once per lifetime within 12 G0402 Initial preventive physical examination; face to face N Category 1 months of visits, services limited to new beneficiary during the enrollment first 12 months of enrollment G0403 Electrocardiogram, routine ECG with 12 leads; N permed as a screening the initial preventive physical examination with interpretation and report G0404 Electrocardiogram, routine ECG with 12 leads; tracing N only, without interpretation and report, permed as a screening the initial preventive physical exam G0405 Electrocardiogram, routine ECG with 12 leads; N interpretation and report only, permed as a screening the initial preventive physical exam Once per calendar year all members as well as one wellwoman exam per calendar year female members. Up to 10 visits children up to 4 years of age (through the 3rd year) Preventive E/M, new patient; years Category 1 Annual Physical: Preventive E/M, new patient; years Category 1 Z00.00, Z Preventive E/M, new patient; 65+ years Category Preventive E/M, established patient; years Category 1 Well woman: Preventive E/M, established patient; years Category 1 Z01.411, Z Preventive E/M, established patient; 65+ years Category Preventive E/M, new patient; infant Category 1 Well Child: (age younger than 1 year) Z00.110, Z Preventive E/M, established patient; Category 1 Z76.1, Z76.2 infant (age younger than 1 year) Preventive E/M, new patient; early childhood Category 1 Well Child: (1 4 years) Z00.121, Z Preventive E/M, established patient; early childhood Category 1 (1 4 years) Category 1 (5 11 years) Preventive E/M; late childhood Category 1 (5 11 years) Once per calendar year Preventive E/M, new patient; late childhood Once per calendar year all members as well as one wellwoman exam per calendar year female members. Up to 15 prenatal visits are covered as preventive benefits Preventive E/M, new patient; adolescent (12 17 years) Preventive E/M, established patient; adolescent (12 17 years) Appropriate E/M Category 1 Well Child: Z00.121, Z Category 1 Well Woman: Z01.411, Z Appropriate E/M Category 1 Normal pregnancy: Z33.1, Z34.00 Z34.93, Z36 Page 1 Separate Payment Categories: 1 Preventive office visit; 2 payable (Modifier may be required) ; 3 Not paid w/preventive E/M code; 4 Not paid w/ any E/M code
4 Billing Guideline Preventive Services Behavioral/Developmental Screenings Service Description Population Frequency CPT/HCPCS Alcohol/Drug Misuse Depression Developmental Screening Obesity Behavioral Counseling Adults/ Adolescents CPT/HCPCS Description Diagnosis Once per calendar year Alcohol and/or substance abuse (other than Unlimited tobacco) abuse structured screening (et, AUDIT, DAST), and brief intervention (SBI) services; minutes G0442 Annual alcohol screen 15 min Unlimited Adults/ Adolescents Once per calendar year G0444 Annual Depression Screening, 15 minutes Unlimited Children N/A Included in E/M N/A N/A N/A Once per calendar year Developmental testing; limited (eg, Developmental Unlimited Screening Test II, Early Language Milestone Screen), with interpretation and report G0451 Development testing, with interpretation and report Unlimited per standardized instrument m Adults/ Once per calendar year Included in E/M N/A N/A Unlimited Children Service Description Population Frequency CPT/HCPCS Alcohol/Drug Misuse Breast Cancer Prevention Medication Cardiovascular Disease (including use of aspirin) Adults/ Adolescents CPT/HCPCS Description Once per calendar year Alcohol and/or substance abuse (other than tobacco) abuse structured screening (et, AUDIT, DAST), and brief intervention (SBI) services; greater than 30 minutes Up to 4 times per year G0443 Brief face to face behavioral counseling Alcohol Misuse, 15 minutes Women N/A Included in E/M Diagnosis Unlimited Category 3 Unlimited N/A N/A N/A Adults N/A Included in E/M N/A N/A N/A Once per calendar year G0446 Annual face to face intensive behavioral therapy to reduce cardiovascular disease risk; individual, 15 minutes N Category 3 Unlimited ( only) Page 2 Separate Payment Categories: 1 Preventive office visit; 2 payable (Modifier may be required) ; 3 Not paid w/preventive E/M code; 4 Not paid w/ any E/M code
5 Billing Guideline Preventive Services Behavioral Counseling, continued Service Description Population Frequency CPT/HCPCS Diabetes Self Management Training Services (DSMT) Adults 10 hours first year, 2 hours subsequent years (Benefits may vary by employer.) Diet/Nutrition Adults Up to 3 hours per calendar year Folic Acid Supplementation Genetic Counseling BRCA Breast Cancer Interpersonal and Domestic Violence Iron Supplementation (Benefits may vary by employer.) CPT/HCPCS Description G0108 Diabetes outpatient self management training services, individual, per 30 minutes G0109 Diabetes outpatient self management training services, group session (2 or more), per 30 minutes Medical nutrition therapy; initial assessment and intervention, individual, face to face with the patient, each 15 minutes Medical nutrition therapy; re assessment and intervention, individual, face to face with the patient, each 15 minutes Medical nutrition therapy; group (2 or more individual(s)), each 30 minutes G0270 G0271 Pregnancies N/A Included in E/M Obesity Adults Up to 22 visits per calendar year Oral Health Children Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year change in diagnosis, medical condition or treatment regimen Medical nutrition therapy, reassessment and subsequent intervention(s) following second referral in same year change in diagnosis, medical condition, or treatment regimen (including additional hours needed renal disease), group Diagnosis Unlimited Limited to treatment cardiovascular or diet related chronic diseases that are diagnosed by a physician, including but not limited to: 1. Diabetes 2. Heart Disease 3. Kidney Disease 4. Lipid Disorders 5. Malnutrition 6. Obesity Dx codes not specified. N/A N/A N/A Women Up to 4 visits per calendar year Medical genetics and genetic counseling services, Z15.01, Z15.02 each 30 minutes face to face with patient/family S0265 Genetic counseling, under physician supervision, each 15 minutes Women As needed Included in E/M N/A N/A N/A Pregnancies As needed Included in E/M N/A N/A N/A G0447 Face to face behavioral counseling Obesity, Category 3 Unlimited individual, 15 minutes G0473 Face to face behavioral counseling Obesity, group, 30 minutes Children N/A Application of topical fluoride varnish by a physician or other qualified health care professional Category 3 Unlimited Page 3 Separate Payment Categories: 1 Preventive office visit; 2 payable (Modifier may be required) ; 3 Not paid w/preventive E/M code; 4 Not paid w/ any E/M code
6 Behavioral Counseling, continued Billing Guideline Preventive Services Service Description Population Frequency CPT/HCPCS Sexually Transmitted Infections (STIs) Adults / Adolescents Tobacco Use Adults Up to 8 sessions (any combination of codes) per year Cancer Screenings CPT/HCPCS Description Diagnosis N/A Included in E/M N/A N/A N/A Up to 2 times per calendar year G0445 Semi annual high intensity behavioral counseling to prevent STIs, individual, face to face includes education skills training & guidance on how to change sexual behavior N Category 3 Unlimited ( only) Smoking and tobacco use cessation counseling visit; Category 3 Unlimited intensive, greater than 3 minutes up to 10 minutes Smoking and tobacco use cessation counseling visit; Category 3 intensive, greater than 10 minutes Up to 8 sessions (any G0436 Smoking and tobacco cessation counseling visit Category 3 combination of codes) per year the asymptomatic patient; intermediate, greater G0437 Service Description Population Frequency CPT/HCPCS than 3 minutes, up to 10 minutes Smoking and tobacco cessation counseling visit the asymptomatic patient; intensive, greater than 10 minutes CPT/HCPCS Description Breast Cancer Women Once per calendar year Computer aided detection with further physician review interpretation, with or without digitization of film radiographic images; diagnostic mammography Computer aided detection with further physician review interpretation, with or without digitization of film radiographic images; screening mammography Category 3 Diagnosis Unlimited women >35; Mammography; unilateral Mammography; bilateral For high risk women <35: Z85.3, Z80.3, Z12.31 Page 4 Separate Payment Categories: 1 Preventive office visit; 2 payable (Modifier may be required) ; 3 Not paid w/preventive E/M code; 4 Not paid w/ any E/M code
7 Billing Guideline Preventive Services Cancer Screenings, continued Service Description Population Frequency CPT/HCPCS CPT/HCPCS Description Diagnosis Breast Cancer, continued Women Once per calendar year G0202 Screening mammography, bilateral (2 view film study of each breast) Screening mammography, producing direct digital Unlimited women >35; G0204 image, bilateral, all views Diagnostic mammography, producing direct digital For high risk women <35: G0206 image, bilateral, all views Diagnostic mammography, producing direct digital Z85.3, Z80.3, Z12.31 image, unilateral, all views Screening digital tomography of both breasts Cervical Cancer Women Once per calendar year Cytopathology, cervical or vaginal (any reporting system), requiring interpretation by physician Cytopathology, cervical or vaginal (any reporting Z01.411, Z01.419, Z01.42, Z11.51, Z12.4, Z12.72, system), collected in preservative fluid, automated thin layer preparation; manual screening under physician supervision Z Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; with manual screening and rescreening under physician supervision Cytopathology smears, cervical or vaginal; screening by automated system Cytopathology smears, cervical or vaginal; screening by automated system with manual rescreening Cytopathology, slides, cervical or vaginal; manual screening under physician supervision Cytopathology, slides, cervical or vaginal; with manual screening and computer assisted rescreening Cytopathology, slides, cervical or vaginal; with manual screening and rescreening Cytopathology, slides, cervical or vaginal; with manual screening and computer assisted rescreening using cell selection and review Page 5 Separate Payment Categories: 1 Preventive office visit; 2 payable (Modifier may be required) ; 3 Not paid w/preventive E/M code; 4 Not paid w/ any E/M code
8 Billing Guideline Preventive Services Cancer Screenings, continued Service Description Population Frequency CPT/HCPCS Cervical Cancer, continued CPT/HCPCS Description Diagnosis Women Once per calendar year Cytopathology, slides, cervical or vaginal, definitive hormonal evaluation Cytopathology, smears, any other source; screening Z01.411, Z01.419, Z01.42, Z11.51, Z12.4, Z12.72, and interpretation Z Cytopathology, smears, any other source; preparation, screening and interpretation Cytopathology, smears, any other source; extended study involving over 5 slides and/or multiple stains Cytopathology, slides, cervical or vaginal (the Bethesda System); manual screening under physician supervision Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and rescreening under physician supervision Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and computer assisted rescreening under physician supervision Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and computer assisted rescreening using cell selection and review under physician supervision Cytopathology, evaluation of fine needle aspirate Cytopathology, evaluation of fine needle aspirate; interpretation and report Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; screening by automated system Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; with screening by automated system and manual rescreening or review Page 6 Separate Payment Categories: 1 Preventive office visit; 2 payable (Modifier may be required) ; 3 Not paid w/preventive E/M code; 4 Not paid w/ any E/M code
9 Billing Guideline Preventive Services Cancer Screenings, continued Service Description Population Frequency CPT/HCPCS Cervical Cancer, continued CPT/HCPCS Description Women Once per calendar year G0101 Cervical or vaginal cancer screening; pelvic and clinical breast examination G0123 Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation G0124 Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, requiring interpretation by physician G0141 Screening cytopathology smears, cervical or vaginal, permed by automated system, with manual rescreening, requiring interpretation by physician G0143 Screening cytopathology, cervical or vaginal, collected in preservative fluid G0144 Screening cytopathology, cervical or vaginal, collected in preservative fluid, automated thin layer preparation, with screening by automated system G0145 Screening cytopathology, cervical or vaginal, collected in preservative fluid, automated thin layer preparation, with screening by automated system and manual rescreening G0147 Screening cytopathology smears, cervical or vaginal, permed by automated system G0148 Screening cytopathology smears, cervical or vaginal, permed by automated system with manual rescreening P3000 Screening papanicolaou smear, cervical or vaginal, up to three smears, by technician under physician supervision P3001 Screening papanicolaou smear, cervical or vaginal, up to three smears, requiring interpretation by physician Q0091 Screening papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory Diagnosis Category 3 Z01.411, Z01.419, Z01.42, Z11.51, Z12.4, Z12.72, Z12.79 Category 3 Page 7 Separate Payment Categories: 1 Preventive office visit; 2 payable (Modifier may be required) ; 3 Not paid w/preventive E/M code; 4 Not paid w/ any E/M code
10 Billing Guideline Preventive Services Cancer Screenings, continued Service Description Population Frequency CPT/HCPCS CPT/HCPCS Description Diagnosis Colorectal Cancer Adult members aged 50+ or younger if at highrisk Fecal Occult Blood Test Once every 12 months. Flexible Sigmoidoscopy Once every 3 years after the last flexible sigmoidoscopy or barium enema, or 10 years after a previous screening colonoscopy. Screening Colonoscopy Once every 10 years, or 3 years after a previous flexible sigmoidoscopy. More frequent screening is available high risk members based on applicable guidelines (generally every 2 years). Barium Enema Once every 3 years when used instead of sigmoidoscopy or colonoscopy. More frequent screening is available highrisk members based on applicable guidelines (generally every 2 years) Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) Low Risk: Z12.11, Z12.12, Z08, Z Sigmoidoscopy, flexible; with biopsy, single or multiple Sigmoidoscopy, flexible; with removal of eign body Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy ceps or bipolar cautery Sigmoidoscopy, flexible; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) Sigmoidoscopy, flexible; with direct submucosal injection(s), any substance Sigmoidoscopy, flexible; with decompression of volvulus, any method 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 removal by hot biopsy ceps, bipolar cautery or snare technique Sigmoidoscopy, flexible; with dilation by balloon, 1 or more strictures Sigmoidoscopy, flexible; with endoscopic ultrasound examination Sigmoidoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s) Sigmoidoscopy, flexible; with transendoscopic stent placement (includes predilation) G0104 Colorectal cancer screening; flexible sigmoidoscopy G0105 Colorectal cancer screening; colonoscopy on individual at high risk G0106 Colorectal cancer screening; alternative to G0104, screening sigmoidoscopy, barium enema G0120 Colorectal cancer screening; alternative to G0105, screening colonoscopy, barium enema G0122 Colorectal cancer screening; barium enema High Risk: Z80.0, Z83.71, Z85.00, Z85.038, Z85.048, Z Note: Facility claims must include Modifier PT or 33. See HFHP s Billing Guideline Invasive Colorectal Cancer Screenings special billing rules. Page 8 Separate Payment Categories: 1 Preventive office visit; 2 payable (Modifier may be required) ; 3 Not paid w/preventive E/M code; 4 Not paid w/ any E/M code
11 Cancer Screenings, continued Billing Guideline Preventive Services Service Description Colorectal Cancer, continued Population Frequency CPT/HCPCS Adult members aged 50+ or younger if at high risk CPT/HCPCS Description See above Blood, occult, by peroxidase activity (eg, guaiac), qualitative; feces, consecutive collected specimens with single determination, colorectal neoplasm screening Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1 3 simultaneous determinations G0328 Colorectal cancer screening; fecal occult blood test, immunoassay, 1 3 simultaneous determinations Diagnosis Low Risk: Z12.11, Z12.12, Z08, Z09 G0464 Colorectal cancer screening; stool based DNA and fecal occult hemoglobin (e.g., KRAS, NDRG4 and BMP3) PRIOR AUTHORIZATION REQUIRED Anesthesia lower intestinal endoscopic procedures, endoscope introduced distal to duodenum Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression Colonoscopy, flexible, proximal to splenic flexure; with removal of eign body Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple Colonoscopy, flexible, proximal to splenic flexure; w/directed submucosal injection(s), any substance Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding (eg, 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 ceps, 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 ceps 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 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(ies) G0105 Colonoscopy on individual at high risk N G0121 Colonoscopy on individual not meeting criteria high risk N High Risk: Z80.0, Z83.71, Z85.00, Z85.038, Z85.048, Z Note: Facility claims must include Modifier PT or 33. See HFHP s Billing Guideline Invasive Colorectal Cancer Screenings special billing rules. Page 9 Separate Payment Categories: 1 Preventive office visit; 2 payable (Modifier may be required) ; 3 Not paid w/preventive E/M code; 4 Not paid w/ any E/M code
12 Billing Guideline Preventive Services Cancer Screenings, continued Service Description Population Frequency CPT/HCPCS Lung Cancer Prostate Cancer Asymptomatic members aged () or aged () who smoke or quit in last 15 years. Men aged 50+ or younger if at high risk Once per calendar year PRIOR AUTHORIZATION REQUIRED S8032 CPT/HCPCS Description Low dose computed tomography lung cancer screening Once per calendar year Prostate specific antigen (PSA); complexed (direct measurement) Diagnosis Unlimited Z Prostate specific antigen (PSA); total Prostate specific antigen (PSA); free G0102 Prostate cancer screening; digital rectal Category 4 Unlimited examination G0103 Prostate cancer screening; prostate specific antigen test (PSA) Other Lab Tests Service Description Population Frequency CPT/HCPCS Anemia Urinalysis (Bacteriuria) Adults/ Pregnancies Adults/ Pregnancies Pregnancy: Unlimited Others: Once per calendar year CPT/HCPCS Description Page 10 Separate Payment Categories: 1 Preventive office visit; 2 payable (Modifier may be required) ; 3 Not paid w/preventive E/M code; 4 Not paid w/ any E/M code Diagnosis Unlimited Urinalysis, by dip stick or tablet reagent; non Blood count; spun microhematocrit Z Hematocrit (Hct) Hemoglobin (Hgb) Blood count; complete (CBC) and automated differential WBC count Blood count; complete (CBC) Z00.00, Z00.01, automated, with microscopy Z00.8, Z01.411, Urinalysis, by dip stick or tablet reagent; Z automated, with microscopy Urinalysis, by dip stick or tablet reagent; automated, with microscopy Urinalysis, by dip stick or tablet reagent; nonautomated, without microscopy Urinalysis, qualitative or semiquantitative, except immunoassays Urinalysis, qualitative or semiquantitative, except immunoassays; bacteriuria screen, except by culture or dipstick
13 Billing Guideline Preventive Services Other Lab Tests, continued Service Description Population Frequency CPT/HCPCS BRCA Analysis Women Once per lifetime Chlamydia Adults / Adolescents PRIOR AUTHORIZATION REQUIRED CPT/HCPCS Description Breast cancer 1 and 2 (BRCA1, BRCA2) full sequence gene analysis and analysis of full duplication and deletion variants BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis and common duplication/deletion variants in BRCA BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and ovarian cancer) gene analysis BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and ovarian cancer) gene analysis; uncommon duplication/deletion variants BRCA1 (breast cancer 1) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis and common duplication/deletion variants BRCA1 (breast cancer 1) (eg, hereditary breast and ovarian cancer) gene analysis; known familial variant BRCA2 (breast cancer 2) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis BRCA2 (breast cancer 2) (eg, hereditary breast and ovarian cancer) gene analysis; known familial variant Diagnosis Unlimited Unlimited Culture, chlamydia, any source Unlimited Infectious agent antigen detection by immunofluorescent technique; Chlamydia trachomatis Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple step method; Chlamydia trachomatis Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, direct probe technique Page 11 Separate Payment Categories: 1 Preventive office visit; 2 payable (Modifier may be required) ; 3 Not paid w/preventive E/M code; 4 Not paid w/ any E/M code
14 Service Description Population Frequency CPT/HCPCS Chlamydia, cont. Adults / Adolescents Cholesterol Adults / Children Diabetes General Health/ Metabolic Panels Adults/ Pregnancies CPT/HCPCS Description Unlimited Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, quantification Infectious agent antigen detection by immunoassay with direct optical observation; Chlamydia trachomatis : Once every 5 calendar years : Once per calendar year Up to 2 per calendar year Once per calendar year Pregnancy Unlimited Billing Guideline Preventive Services Page 12 Separate Payment Categories: 1 Preventive office visit; 2 payable (Modifier may be required) ; 3 Not paid w/preventive E/M code; 4 Not paid w/ any E/M code Diagnosis Unlimited Lipid panel Z13.220, Z Total cholesterol HDL C VLDL C LDL C Triglycerides Glucose; quantitative, blood Z Glucose; post glucose dose (includes glucose) Glucose; tolerance test (GTT), 3 specimens Pregnancy: (includes glucose) Z33.1, Z Basic metabolic panel (Calcium, ionized) Z34.93, Z36 Adults Once per calendar year Basic metabolic panel (Calcium, total) Z00.00, Z General health panel Comprehensive metabolic panel Gonorrhea Adults / Unlimited Infectious agent detection by nucleic acid); Unlimited Adolescents Neisseria gonorrhoeae, direct probe technique Infectious agent detection by nucleic acid; Neisseria gonorrhoeae, amplified probe technique Infectious agent detection by nucleic acid; Neisseria gonorrhoeae, quantification Infectious agent antigen detection by immunoassay with direct optical observation; Neisseria gonorrhoeae Hemoglobinopathies Newborns Unlimited Sickling of RBC, reduction Unlimited Hepatitis B Pregnancies Unlimited Hepatitis B core antibody (HBcAb); total Unlimited Hepatitis B core antibody (HBcAb); IgM antibody Hepatitis B surface antibody (HBsAb) Infectious agent antigen detection by immunoassay technique; hepatitis B surface antigen (HBsAg) Hepatitis C High Risk Unlimited Hepatitis C antibody individuals G0472 Hepatitis C antibody screening individual at high risk and other covered indication(s) Unlimited Herpes High Risk individuals Unlimited Antibody; herpes simplex, non specific type test Antibody; herpes simplex, type Antibody; herpes simplex, type 2 Unlimited
15 Service Description Population Frequency CPT/HCPCS HIV High Risk individuals CPT/HCPCS Description Billing Guideline Preventive Services Diagnosis Unlimited HTLV or HIV antibody, confirmation test Unlimited Antibody; HIV Antibody; HIV Antibody; HIV 1 and HIV 2, single assay Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple step method; HIV 1 antigen(s), with HIV 1 and HIV 2 antibodies Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple step method; HIV Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple step method; HIV Infectious agent detection by nucleic acid (DNA or RNA); HIV 1, direct probe technique Infectious agent detection by nucleic acid (DNA or RNA); HIV 1, amplified probe technique, includes reverse transcription when permed Infectious agent detection by nucleic acid (DNA or RNA); HIV 1, quantification, includes reverse transcription when permed Infectious agent detection by nucleic acid (DNA or RNA); HIV 2, direct probe technique Infectious agent detection by nucleic acid (DNA or RNA); HIV 2, amplified probe technique, includes reverse transcription when permed Infectious agent detection by nucleic acid (DNA or RNA); HIV 2, quantification, includes reverse transcription when permed Infectious agent antigen detection by immunoassay with direct optical observation; HIV 1 antigen(s), with HIV 1 and HIV 2 antibodies G0432 Infectious agent antigen detection by EIA technique, qualitative or semi qualitative, multiple step method, HIV 1 or HIV 2, screening G0433 Infectious agent antigen detection by ELISA technique, antibody, HIV 1 or HIV 2, screening G0435 Infectious agent antigen detection by rapid antibody test of oral mucosa transudate, HIV 1 or HIV 2, screening Page 13 Separate Payment Categories: 1 Preventive office visit; 2 payable (Modifier may be required) ; 3 Not paid w/preventive E/M code; 4 Not paid w/ any E/M code
16 Billing Guideline Preventive Services Service Description Population Frequency CPT/HCPCS CPT/HCPCS Description Diagnosis HPV DNA Testing Females Unlimited Infectious agent detection by nucleic acid (DNA Unlimited or RNA); Human Papillomavirus (HPV), low risk types Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), high risk types Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), types 16 and 18 only, includes type 45, if permed Hypothyroidism Adults/Children Once per calendar year Thyroid Stimulating Hormone (TSH) Z13.29 Lead Children Unlimited Lead Unlimited Obstetric Panel Pregnancy Unlimited Obstetric panel Z33.1, Z Obstetric panel including HIV Z34.93, Z36 PKU Screening Newborns Unlimited Phenylalanine (PKU), blood Unlimited RH Incompatibility Pregnancies Unlimited Blood typing; ABO Unlimited Blood typing; Rh (D) Syphilis Adults/ Adolescents Unlimited Syphilis test, non treponemal antibody; qual. Unlimited Other Screenings Service Description Population Frequency CPT/HCPCS Abdominal Aortic Aneurism Screening Adult men or women Men only Once per lifetime at risk individuals G0389 CPT/HCPCS Description Ultrasound B scan and/or real time with image documentation; abdominal aortic aneurysm (AAA) screening Diagnosis Unlimited Bone Density (Osteoporosis) Screening Adults Once every 2 years all women >60 years of age. Additional preventive coverage high risk members Other tests covered under radiology benefit Ultrasound bone density measurement and interpretation, peripheral site(s), any method Computed tomography, bone mineral density study, 1 or more sites; axial skeleton Dual energy X ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton Dual energy X ray absorptiometry (DXA), bone density study, 1 or more sites; appendicular skeleton (peripheral) G0130 Single energy x ray absorptiometry (sexa) bone density study, one or more sites; appendicular skeleton (peripheral) Z See LCD Bone Mass Measurement (L34639) additional diagnosis codes. Available at N Same as above ( only) Page 14 Separate Payment Categories: 1 Preventive office visit; 2 payable (Modifier may be required) ; 3 Not paid w/preventive E/M code; 4 Not paid w/ any E/M code
17 Billing Guideline Preventive Services Service Description Population Frequency CPT/HCPCS CPT/HCPCS Description Diagnosis Glaucoma Screening Adults Once per calendar year G0117 Glaucoma screening high risk patients Unlimited furnished by an optometrist or ophthalmologist G0118 Glaucoma screening high risk patient furnished under the direct supervision of an optometrist or ophthalmologist Hearing Children/ Once per calendar year Screening test, pure tone, air only Others with Pure tone audiometry (threshold); air only Z01.10, Z Enhanced Benefits Tympanometry (impedance testing) Tuberculin Test Children Unlimited < age Skin test; tuberculosis, intradermal Unlimited Vision Screening Children/ Others with Enhanced Benefits Once per calendar year Screening test of visual acuity, quantitative, bilateral Ocular photoscreening with interpretation and report, bilateral Unlimited Breastfeeding Services and Supplies Service Description Population Frequency CPT/HCPCS CPT/HCPCS Description Diagnosis Breast Pumps Pregnancies 1 type of breast pump per live E0603 Breast pump, electric (AC and/or DC), any type N Unlimited birth E0604 Breast pump, hospital grade, electric N ( only) As needed A4281 Tubing breast pump, replacement N Breastfeeding (Lactation) Counseling As needed A4282 Adapter breast pump, replacement N A4284 Breast shield and splash protector use with N breast pump, replacement A4286 Locking ring breast pump, replacement N Use E/M or N/A N Category 3 Z39.1, O92.3, O92.4, Counseling O92.5, O93.70, O92.79 Page 15 Separate Payment Categories: 1 Preventive office visit; 2 payable (Modifier may be required) ; 3 Not paid w/preventive E/M code; 4 Not paid w/ any E/M code
18 Billing Guideline Preventive Services Contraceptive Services and Supplies Service Description Population Frequency CPT/HCPCS CPT/HCPCS Description Diagnosis Contraception Women As prescribed Removal, implantable contraceptive capsules N Unlimited ( only) Insertion, non biodegradable drug delivery N implant Removal, non biodegradable drug delivery N Z30.2, Z implant Z Removal, with reinsertion, non biodegradable N drug delivery implant Diaphragm or Cervical Cap fitting with N instructions Insertion of intrauterine device (IUD) N Unlimited ( only) Removal of IUD N Catheterization and introduction of saline or contrast material saline infusion sonohysterography (SIS) or N hysterosalpingography Transcervical introduction of fallopian tube N Z30.2, Z30.8, Z30.40 catheter diagnosis and/or re establishing patency (any method), with or without hysterosalpingography Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants N Unlimited ( only) 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 bilateral, during same hospitalization Ligation or resection of fallopian tube(s) when done at the time of cesarean delivery or intraabdominal surgery (not a separate procedure) Occlusion of fallopian tubes by device (e.g., band, clip, Falope ring) vaginal or suprapubic approach Laparoscopy; with removal of adnexal structures (partial/total oophorectomy/ salpingectomy) N Unlimited ( only) N N N N Page 16 Separate Payment Categories: 1 Preventive office visit; 2 payable (Modifier may be required) ; 3 Not paid w/preventive E/M code; 4 Not paid w/ any E/M code
19 Billing Guideline Preventive Services Contraceptive Services and Supplies, continued Service Description Population Frequency CPT/HCPCS CPT/HCPCS Description Surgical laparoscopy, with fulguration of oviducts N Surgical laparoscopy, with occlusion of oviducts N Salpingectomy, complete or partial, unilateral or N bilateral (separate procedure) Hysterosalpingography, radiological supervision N and interpretation A4261 Cervical cap contraceptive use N A4264 Permanent implantable contraceptive intratubal N occlusion device(s) and delivery system A4266 Diaphragm contraceptive use N J1050 Injection, medroxyprogesterone acetate N Therapeutic, prophylactic, or diagnostic injection N (specify substance or drug); subcutaneous or intramuscular J7300 Intrauterine copper contraceptive N J7301 Levonorgestrel releasing intrauterine N contraceptive system (Skyla), 13.5 mg J7302 Levonorgestrel releasing intrauterine N contraceptive system, 52 mg J7304 Contraceptive supply, hormone containing patch N J7306 Levonorgestrel (contraceptive) implant system, N including implants and supplies J7307 Etonogestrel (contraceptive) implant system, N including implant and supplies S4989 Contraceptive intrauterine device, including N implants and supplies Men As prescribed Vasectomy, unilateral or bilateral Diagnosis Note: Vasectomies only covered as a preventive benefit in physician office setting. Revision History 4/1/16 Added (Hepatitis B), 86694, 86695, (Herpes) 1/1/16 Added (Obstetric Panel with HIV), (BRCA1, BRCA2) Health First Plans, Inc. and Health First Insurance, Inc., are both doing business under the name of Health First Health Plans. Health First Health Plans does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations. Page 17 Separate Payment Categories: 1 Preventive office visit; 2 payable (Modifier may be required) ; 3 Not paid w/preventive E/M code; 4 Not paid w/ any E/M code
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