Blue represents coding updates. 6/30/12 cancel 99408

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1 An Independent Licensee of the Blue Cross and Blue Shield Association Preventive Care Services The following is a list of preventive services (HCP rider) along with the diagnoses and procedure codes that Blue Cross and Blue Shield of Alabama has determined to meet and in some situations exceed the requirements and recommendations issued by the Affordable Care Act (healthcare reform). Some or all of the contraceptives Methods or prescription drugs listed may not be covered under the plan because of the employer s religious beliefs. To find out if contraceptives methods and prescriptions drugs are excluded, please contact Customer Service for additional information. **Services are still subject to Medical Management Criteria.** Blue represents coding updates. Description ICD9 Code Prior to 10/1/15 ICD10 Code Effective 10/1/15 Notes Abdominal Aortic Aneurysm, Screening Males only (with any history of smoking) Ages years One in a lifetime Alcohol Misuse Screening and Behavioral Counseling Interventions One each calendar year (as needed) G0389 with V81.2, V15.82, or with V79.1, or /1/12 add G0442 and G0443 G0389 with Z13.6, Z72.0, Z87.891, or F F17.219, F F with Z13.89, or F10.10, F10.120, F /1/12 add G0442 and G0443 age restriction set up at years 6/30/12 cancel /30/12 cancel Aspirin for the Prevention of Cardiovascular Disease men ages years women ages years Once every 5 calendar years Asymptomatic Bacteriuria in Pregnant Women, Screening 99401, 99386, 99387, 99396, or with V65.8 1/1/12 add G , 87084, 87086, or with V V23.0, , V91.00-V91.03, V91.09-V91.12, V91.19-V91.22, V91.29, V91.90-V91.92, V91.99, or V , 99386, 99387, 99396, or with Z13.6 or Z /1/12 add G , 87084, 87086, or with O09.00-O09.03, O09.40 O09.529, O O15.03, O15.2-O21.9, O O26.43, O O26.93, O O30.019, O O35.6XX9, O35.8XX0- O36.73X9, O O , O O42.019, O O42.119, O42.90-O42.919, O O43.119, O O43.199, O O61.9, O67.0-O68, O75.2, O75.3, O75.5, O75.82-O77.0, O80, O86.11, O86.13-O86.29, O90.5- age restriction set up at years and years

2 O90.89, O O9A.53, Z13.89, Z33.1, or Z34.00-Z34.93 Breast and Ovarian Cancer Susceptibility, Genetic Risk Assessment and BRCA Mutation Testing Females only One session in a lifetime 96040, or with V16.3, V16.41, V26.33, or V84.01 Effective February 20, , 81212, 81213, 81214, 81215, and , or with Z15.01, Z31.5, Z80.3, or Z80.41 Effective February 20, , 81212, 81213, 81214, 81215, and combined with chemo prevention of breast cancer 9/1/15 add V10.3 or V10.43 Effective 9/1/15 add Z85.3 or Z85.42 Breast Cancer Prevention Medication Effective 10/1/2014 Pharmacy only Females only age 35 and older To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy. To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy. Breastfeeding, Behavioral Interventions to Promote Females only Twice per calendar year Cervical Cancer, Screening (PAP Smear) also known as Cervical Dysplasia Screening One each calendar year No age limitations Chemoprevention of breast cancer Females only One in a lifetime must have modifier TH and V22.0-V23.9 or V , 88142, 88143, 88147, 88148, 88150, 88152, 88153,88154, 88155, 88164, 88165, 88166, 88167, 88174, 88175, G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001, or Q0091 with 99401, or with code V16.3 or V must have modifier TH and O09.00-O09.93, O36.80X0-O36.80X9, Z33.1, Z34.00-Z34.93 or Z , 88142, 88143, 88147, 88148, 88150, 88152, 88153,88154, 88155, 88164, 88165, 88166, 88167, 88174, 88175, G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001, or Q0091 with 99401, or with code Z80.3 or Z15.01 *Also see additional benefits in Women s Preventive section at the bottom of this document combined with BRCA benefit above Chlamydia Infection, Screening Females age One each calendar year 87110, 87270, 87320, 87490, 87491, 87492, or with except V , 87270, 87320, 87490, 87491, 87492, or with except Z11.3 Chlamydia split due to V74.5 overlapping with STI Screening preventing visit maximums from applying correctly Revised 10/19/2015 YPE Page 2

3 (see STI Screening) Or 87800, 86631, with V73.88 or V73.98 (see STI Screening) Or 87800, 86631, with Z11.8 Females age One each calendar year 87110, 87270, 87320, 87490, 87491, 87492, or with Or 87800, 86631, with V73.88 or V , 87270, 87320, 87490, 87491, 87492, or with Or 87800, 86631, with Z11.8 Effective 12/1/2014 Females age One each calendar year 87110, 87270, 87320, 87490, 87491, 87492, or with except V74.5 (see STI Screening) Or 87800, 86631, with V73.88 or V , 87270, 87320, 87490, 87491, 87492, or with except Z11.3 (see STI Screening) Or 87800, 86631, with Z11.8 Females age One each calendar year 87110, 87270, 87320, 87490, 87491, 87492, or with Or 87800, 86631, with V73.88 or V , 87270, 87320, 87490, 87491, 87492, or with Or 87800, 86631, with Z11.8 Routine Cholesterol (Lipid Disorders in Adults), Screening Men age 35 years and older (20-35 at risk for CAD) Women age 45 years and older (20-45 at risk for CAD) One every 5 calendar year Colorectal Cancer, Screening or with routine Same as COL rider or with routine Same as COL rider Age restriction set up at years Age restriction set up at years Colonoscopy Once every 10 calendar years Ages years Includes outpatient facility services, physician services, and anesthesia. Colonoscopy G0121, G0105, G6019, G6020, G6021, G6024, G6025, 44388, 44389, 44390, 44391, 44392, 44393, 44394, 44401, 44402, Colonoscopy G0121, G0105, G6019, G6020, G6021, G6024, G6025, 44388, 44389, 44390, 44391, 44932, 44393, 44394, 44401, 44402, Anesthesia Prior to 07/01/ , , with Effective 07/01/11 Revised 10/19/2015 YPE Page 3

4 44404, 44405, 44406, 44407, 45378, 45379, 45380, 45381, 45382, 45384, 45385, 45386, 45389, 45391, or , 44405, 44406, 44407, 45378, 45379, 45380, 45381, 45382, 45384, 45385, 45386, 45389, 45391, or , , covered when medical criteria is satisfied. (See Medical Policy # 470, Monitored Anesthesia Care) **12/31/14 delete codes 44393, 44397, 45355, 45383, **12/31/14 delete codes 44393, 44397, 45355, 45383, Age restriction set up at years **1/1/15 add codes 44401, 44402, 44404, 44405, 44406, 44407, 45388, 45389, G6019, G6020, G6024. G6025 **1/1/15 add codes 44401, 44402, 44404, 44405, 44406, 44407, 45388, 45389, G6019, G6020, G6024. G6025 Age restriction set up at years Sigmoidoscopy Ages years Once every 3 calendar years Barium Enema Part of standard COL Ages years Once every 5 calendar years Hemoccult Ages years One each calendar year Congenital Hypothyroidism, Screening Newborns - ages 2-4 days Anesthesia 00810, , With Sigmoidoscopy G0104 or with routine Barium Enema G0106, G0120, G0122, or with Hemoccult G0107, G0328, G0394, 82270, 82272, or with routine 84436, 84437, 84439, or with V77.0 Anesthesia 00810, , With Sigmoidoscopy G0104 or with routine Barium Enema G0106, G0120, G0122, or with Hemoccult G0107, G0328, G0394, 82270, 82272, or with routine 84436, 84437, 84439, or with Z13.29 Age restriction set up at years Per USPSTF recommendation - Clinical Considerations Patient Population under Consideration - These recommendations apply to adults 50 years of age and older, excluding those with specific inherited syndromes (the Lynch syndrome or familial adenomatous polyposis) and those with inflammatory bowel disease. The recommendations do apply to those with firstdegree relatives who have had colorectal adenomas or cancer, although for those with first-degree relatives who developed cancer at a younger age or those with multiple affected first-degree relatives, an earlier start to screening may be reasonable. Furthermore, when the screening test results in the of clinically significant colorectal adenomas or cancer, the patient will be followed by a surveillance regimen and recommendations for screening are no longer applicable. Dental Caries in Children From Birth Through Age 5 Years, Prevention of Effective 6/1/2015 Birth 5 years CPT with V07.31 CPT with Z41.8 Revised 10/19/2015 YPE Page 4

5 Male and Females Maximum 4 per calendar year Dental Caries in Preschool Children, Prevention Included in preventive office visit Included in preventive office visit Depression, Screening with V with Z13.89 Ages 12 years and older One each calendar year 1/1/12 add G0444 1/1/12 add G0444 Effective 1/1/2015 Ages 11 years and older 6/30/12 cancel /30/12 cancel One each calendar year Developmental Screening with with Ages 9-30 months Four services during age range 1/1/12 add G0451 1/1/12 add G0451 Effective 1/1/2015 Ages 9-30 months Five services during age range Developmental Surveillance for Children Included as part of an office visit Included as part of an office visit Developmental/Behavioral Assessment Alcohol and Drug Ages years One each calendar year G0396, H0001, or with V69.8 or V69.9 1/1/12 add G0442, G0443 6/30/12 cancel G0396, H0001, or with Z72.0, Z72.89, Z72.9, or Z73.9 1/1/12 add G0442, G0443 6/30/12 cancel Dyslipidemia Screening Ages 2-10 years: Once every 2 calendar years Ages years: One each calendar year Ages years: Once during age range Behavioral Counseling in Primary Care to Promote a Healthy Diet (Diet Counseling) Three hours each calendar year Ages 19 and older with V with Z , G0270 or G0271 with V65.3, , , , , , , , 429.9, , , , V85.30-V85.39, V V85.45, 357.2, , , , , , , , G0270 or G0271 with Z71.3, A18.84, E08.00 E13.9, E66.01-E66.1, E66.8, E66.9, I10-I22.9, I24.0- I25.9, I42.0-I43, I50.1- I50.9, I51.5-I51.7, I51.9, I52, N26.2, O O24.33, O O24.93, O O99.215, or Z68.30-Z68.45 Revised 10/19/2015 YPE Page 5

6 or /1/12 add G0446 Gonorrhea, Screening Female only ages (Ages included in STI screening) Two each calendar year 1/1/12 add G , 87591, 87850, or with V , 87591, 87850, or with Z11.3 Ages changed due to already included in the STI Screening, again preventing visit maximums from applying correctly Gonorrhea, Prophylactic Medication, Newborn Hematocrit or Hemoglobin Ages 4 months-10 years, no more than 3 tests. Ages years--one each calendar year Hepatitis B Virus Infection in Pregnancy, Screening for Females (pregnant) One each calendar year Hepatitis B Virus Infection in Nonpregnant Adolescents and Adults, Screening for Effective 6/1/2015 Ages Females and Males One each CPT code per calendar year No code available - usually administered as an ancillary charge while inpatient at time of delivery or with V and V22.0- V , 86705, 86706, or with V08, V12.09, V12.29, V15.85, V45.11, V56.0, V58.11, V58.12, V61.49, V62.5, V87.46, V , , , , or No code available - usually administered as an ancillary charge while inpatient at time of delivery or with Z and O O09.93, O36.80X0-O36.80X9, Z33.1, or Z34.00-Z , 86705, 86706, or with Z21, Z51.11, Z51.12, Z57.8, Z63.6, Z63.79, Z65.1, Z65.2, Z77.21, Z86.19, Z86.2, Z92.25, Z92.29, Z99.2, B17.10, B17.11, B18.2, B19.20 or B19.21 Hepatitis C Virus (HCV) Infection, Screening Once per lifetime screening for males and females Once per year* screening for males and females AND with: born 1945 through 1965 OR with dx code V18.3 (being born to an HCVinfected mother) OR AND with: born 1945 through 1965 OR with dx code Z83.2 (being born to an HCVinfected mother) for dx codes V87.49, V15.85, V45.11, V62.5 for dx codes Z92.29, Z77.21, Z99.2, Z65.1, Z65.2, Z /1/14 add G /1/14 add G0472 High Blood Pressure, Screening Usually included as part of an Usually included as part of an OR *For frequency once per year for risk groups if high risk behavior has ever occurred and person never screened previously, or high risk behavior has occurred since last screening (clinical consideration in study by USPSTF 60% of new HCV infections occur in persons who report injection drug use within the past 6 months ) Revised 10/19/2015 YPE Page 6

7 One each calendar year as needed. Ages 18 years and older HIV, Screening Ages 11 years and older No frequency *Beginning August 1, 2012 for females beginning at age 10. office visit 86701, 87535, 87534, 87390, 86703, G0432, G0433, or G0435 with V /1/12 add office visit 86701, 87535, 87534, 87390, 86703, G0432, G0433, or G0435 with Z11.4 1/1/12 add Human Papillomavirus (HPV) Part of Standard PMD Ages years Females only One every 3 calendar years 1/1/15 add code , 87621, or with 12/31/14 delete 87620, 87621, /1/15 add 87623, 87624, or with 1/1/15 add code , 87621, or with 12/31/14 delete 87620, 87621, /1/15 add 87623, 87624, or with Immunizations See Routine Immunizations Standard PMD Contracts on DORS See Routine Immunizations Standard PMD Contracts on DORS Inpatient Newborn Care Newborns Inpatient physician services only , , , 99238, 99239, 99460, , with a Inpatient physician services only , , , 99238, 99239, 99460, , with a Iron Deficiency Anemia, Prevention Pharmacy Benefit Pharmacy Benefit Iron Deficiency Anemia, Screening Females (pregnant) One each calendar year Lead Screening Ages 6 months 6 years 3 tests during age range 85013, 85014, 85018, 85025, or with V22.0- V , 85014, 85018, 85025, or with O O09.93, O36.80X0-O36.80X9, Z33.1, or Z34.00-Z with V with Z13.88 Lung Cancer, Screening with Low-Dose Computed Tomography Effective 1/1/ or S8032 with V76.0 and V or S8032 with Z12.2 and Z Revised 10/19/2015 YPE Page 7

8 55-80 years old Male and Females One each calendar year Mammography and Digitization One baseline for females ages years One annually for females age 40 and over Newborn Metabolic/Hemoglobin Screening Ages 0-2 months One test during age range Newborn Screening Panel Ages birth-31 days Obesity in Adults and Children Screening. Ages 6 years and older One per calendar year G0202, G0204, G0206, , 77055, 77056, or with Effective 08/01/2012 add V16.3 and V76.11 as a high risk S3620 with no specific required with routine V or with V with routine V with routine V with routine V with routine V or with V with routine V with routine V with routine V with V77.8 1/1/12 add G0447 G0202, G0204, G0206, , 77055, 77056, or with Effective 08/01/2012 add Z80.3 or Z12.31 as a high risk S3620 with no specific required with routine Z or with Z13.21, Z13.228, Z with routine Z with routine Z13.21, Z13.228, Z with routine Z with routine Z or with Z13.21, Z13.228, Z with routine Z with routine Z with routine Z13.21, Z13.228, Z with Z /1/12 add G0447 HCP did not list as covered we included in HCP so there would be no disruption of coverage Revised 10/19/2015 YPE Page 8

9 Oral Health Ages 6 months-6 years. 3 services during age range with V with Z01.20 or Z /31/15 remove Z01.20, Z01.21 Osteoporosis in Postmenopausal Women, Screening 11/1/15 add Z13.84 Effective 10/01/ /31/2012 Ages 65 and older. 60 and older if at risk Females only Once every 4 calendar years (prior to 2/1/12) Effective 02/01/2012 Ages 65 and older. 65 and younger if at risk Females only Once every 2 calendar years with V with V13.51, V13.52, V15.51, V17.81, V45.77, V82.81, V87.45, 305.1, , 720.0, , , , , , , , , , , , , , , , , , , , , , 758.6, , 256.2, , , 253.4, , V12.1, , , or V with Z with E E05.91, E10.10-E10.9, E23.6, E E28.39 E44.0-E46, E64.0, E89.40, E89.41, F F10.220, F10.229, F F17.299, K70.0-K70.40, K70.9, K73.0-K74.69, K75.4, K75.81, K76.0, K76.89, K76.9, K90.0- K90.4, K90.89, K90.9, K91.2, M05.00-M06.9, M08.00-M08.99, M12.00-M12.09, M45.0-M45.9, M48.8X1-M48.8X9, Q78.0, Q96.0-Q96.9, Z71.41, Z72.0, Z82.62, Z86.39, Z Z87.312, Z87.81, Z Z90.79, or Z Age restriction set up at 0-99 years The U.S. Preventive Services Task Force did not make a frequency recommendation. The frequency follows the recommendation made by the American College of Obstetrics and Gynecology. Over-the-Counter Pharmaceuticals Effective 08/01/2013 Aspirin Over the counter Men aged years Women aged years To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy. To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy. Contraceptive Methods Women only Generic only Revised 10/19/2015 YPE Page 9

10 Fluoride Over-the-counter Ages 6 months 6 years Folic Acid Over-the-counter Women only Iron Supplements Over-the-counter Ages 6 months to 12 months Vitamin D Supplements Ages Phenylketonuria, Screening (PKU) Ages 2-14 days Two tests during age range Prostate Specific Antigen (PSA) Ages 40 years and over Annually Rh (D) Incompatibility, Screening Two per calendar year Females only Prenatal Visits Prenatal conference with Pediatricians only Prevention of Falls Age 65 years and older with V with Z G0103 or with routine with V22.0- V or with V , 97112, 97116, G0151, or G0159 with V15.88, limited to 40 services each calendar year (= 10 hours of physical therapy) G0103 or with routine with O O09.93, O36.80X0-O36.80X9, Z33.1, or Z34.00-Z34.93 CPT codes or with Z , 97112, 97116, G0151, or G0159 with Z91.81, limited to 40 services each calendar year (= 10 hours of physical therapy) HCP did not list as covered we included in HCP so there would be no disruption of coverage Effective 6/1/2013 OR with V15.88, limited to 10 services each calendar year OR S9131 with V15.88, limited to 10 services each calendar year OR with Z91.81, limited to 10 services each calendar year OR S9131 with Z91.81, limited to 10 services each calendar year Revised 10/19/2015 YPE Page 10

11 Preventive History and Physical Examinations 9 visits the first 2 years of life Age 2 two per birth year Ages one each year ( based on birth year) Ages 7-99 Male one each calendar year Ages 7-9 Females one each calendar year Ages Females one each calendar year (excludes the Well Women s Preventive Examinations procedure/ code combinations) Psychosocial/Behavioral Assessment Effective 1/1/2015 Newborn 21 years 31 services during age range Sensory Screening Hearing Ages 2 months - 10 years---no more than eight tests, Ages years ----no more than two tests with with 92551, 92552, 92567, 92586, 92587, or V5008 with V20.2 or V /1/12 add , 92552, 92567, 92586, 92587, or V5008 with Z00.121, Z00.129, Z01.10, or Z /1/12 add HCP indicates to cover an additional visit at age 30 months for well child Audiologists are not eligible providers 12/31/11 cancel /31/11 cancel Screening Hearing Newborn Newborn 31 days One in a lifetime or with V20.2, V20.31, V20.32, or V /1/15 add Z or with Z00.110, Z00.111, Z00.121, Z00.129, Z01.10, or Z Audiologists are not eligible providers 1/1/12 add /1/12 add /31/11 cancel /31/11 cancel Sexually Transmitted Infections, Behavioral Counseling Interventions to Prevent Males age Males - Three hours in a lifetime with V65.44, V65.45, or V69.2 1/1/12 add G /1/15 add Z with Z71.7, Z71.89 Z72.51, Z72.52, or Z /1/12 add G0445 Removed code V65.44 for female age due to overlapping with HIV Counseling preventing visit maximums from Revised 10/19/2015 YPE Page 11

12 applying correctly Females age Eff. 8/1/2012 Females once each calendar year Not covered under PMD Sexually Transmitted Infections (STI), Screening Ages years No frequency Sickle Cell Disease, Screening Age 0-31 days No frequency Syphilis Infection, Screening No frequency 99401, with V65.45 or V69.2 OR 99403, with V65.44, V65.45 or V69.2 1/1/12 add G , 86632, 86701, 86703, 87081, 87110, 87205, 87210, 87270, 87320, 87490, 87491, 87590, 87591, 87800, 87810, or with V or with V or with V , with Z71.89, Z72.51, Z72.52 or Z72.53 OR 99403, with Z71.7, Z71.89 Z72.51, Z72.52, or Z /1/12 add G , 86632, 86701, 86703, 87081, 87110, 87205, 87210, 87270, 87320, 87490, 87491, 87590, 87591, 87800, 87810, or with Z or with Z or with Z11.3 Tobacco Use and Tobacco-Caused Disease, Counseling One of each CPT code each calendar year Ages years Effective 5/16/14 8/31/14 8 total per calendar year Ages years 8 total per calendar year Males and Females 99406, 99407, G0436 or G , Pregnant Females Ages for CPT codes or with ICD-9 code of or Males and Females 99406, 99407, G0436 or G , Males and Females 99406, 99407, G0436 or G0437 F F17.299, or Z72.0, Pregnant Females Ages for CPT codes or with ICD-10 codes of O O Males and Females 99406, 99407, G0436 or G0437 F F17.299, or Z72.0, Revised 10/19/2015 YPE Page 12

13 Ages years Pregnant Females Ages for CPT codes or with ICD-9 code of or Pregnant Females Ages for CPT codes or with ICD-10 codes of O O Effective 9/1/14 8 total per calendar year Ages 6-99 years 8 total per calendar year Ages years Males and Females 99406, 99407, G0436 or G , Pregnant Females Ages for CPT codes or with ICD-9 code of or Males and Females 99406, 99407, G0436 or G0437 F F17.299, or Z72.0, Pregnant Females Ages for CPT codes or with ICD-10 codes of O O Tobacco Use and Tobacco-Caused Disease, Medication Effective 10/1/2014 Two 90 day supplies To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy. To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy. All Food and Drug Administration (FDA)- approved tobacco cessation medications (including both prescription and over-thecounter medications) for a 90-day treatment regimen when prescribed by a health care provider without prior authorization. Type 2 Diabetes Mellitus in Adults, Screening Ages 19 years and older Once every 3 calendar years Tuberculin Test Ages 1 month - 21 years 6 tests during age range or with V or with Z with V with Z11.1 O O Visual Acuity Screening in Children Newborn age 10 limited to 8 tests in age range Ages years limited to 4 tests during age range or with V /1/14 add V20.2, V20.31 or V or with Z01.00 or Z /1/14 add Z00.129, Z00.121, Z or Z /1/15 add Z13.5 Revised 10/19/2015 YPE Page 13

14 *Women s Preventive Screenings Effective August 1, 2012 Description ICD9 Code Prior to 10/1/14 ICD10 Code Effective 10/1/14 Notes Well Woman Preventative Females only beginning at age 10 Effective 8/1/12 CPT codes , G0439, S0612, or S0613 with V70.0 or V72.31 limited to 2 per calendar year Effective 8/1/12 CPT codes , G0439, S0612, or S0613 with Z00.00, Z00.01, Z01.411, or Z limited to 2 per calendar year Effective 8/1/12 7/31/13 CPT codes , G0438, or S0610 with V70.0 or V72.31 limited to 1 per calendar year Effective 8/1/12 7/31/13 CPT codes , G0438, or S0610 with V70.0 or V72.31 limited to 1 per calendar year Effective 8/1/13 CPT codes , G0438, or S0610 with V70.0 limited to 1 per calendar year Effective 8/1/13 CPT codes , G0438, or S0610 with Z00.00 or Z00.01 limited to 1 per calendar year CPT codes , G0438, or S0610 with V72.31 limited to 1 per calendar year CPT codes , G0438, or S0610 with Z or Z limited to 1 per calendar year Preconception Females only beginning at age 10 One visit per calendar year Prenatal Care Females only beginning at age 10 same procedure codes as above with code V with routine prenatal (see HCP ROUTINE PRENATAL DX), limited to 3 visits each calendar year same procedure codes as above with code Z with routine prenatal (see HCP ROUTINE PRENATAL DX), limited to 3 visits each calendar year Codes for prenatal visits should be filed separate from global maternity to ensure member coverage at 100% with no cost share See end of document for a list of dx codes with high risk prenatal (see HCP HIGH RISK PRENATAL DX) with high risk prenatal (see HCP HIGH RISK PRENATAL DX) regardless of, limited to 2 visits each calendar year regardless of, limited to 2 visits each calendar year Revised 10/19/2015 YPE Page 14

15 Description ICD9 Code Prior to 10/1/14 ICD10 Code Effective 10/1/14 Notes regardless of, limited to 1 visit each calendar year regardless of, limited to 1 visit each calendar year Screening for Gestational Diabetes Females only beginning at age 10 Limit two per calendar year HIV Counseling Females only beginning at age 10 Annually Contraceptive Methods and Counseling Female only beginning at age 10 Annually or with codes V22.0-V23.9 or , , , V91.00-V91.03, V V91.12 or V91.19-V91.22, V91.29, V91.90-V91.92, V91.99, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , or or with V with codes V25.01-V25.09, V25.40-V25.49, or V or with codes O09.00-O15.03, O15.2- O23.93, O25.10-O26.43, O O26.93, O O30.019, O O30.93, O31.00X-O32.9XX (7 th character 0,1,2,3,4,5, or 9), O33.0-O33.2, O33.3XX-O33.6XX (7 th character 0,1,2,3,4,5, or 9), O33.7-O34.93, O35.0XX-O35.6XX (7 th character 0,1,2,3,4,5,or 9), O35.8XX0- O , O O41.93X (7 th character 0,1,2,3,4,5, or 9), O42.00-O42.019, O O42.119, O42.90-O42.919, O O43.119,O O43.199, O O60.03, O60.10X (7 th character 0,1,2,3,4,5, or 9), O60.20X0- O60.20X9, O61.0-O61.1, O6.70- O68, O75.2-O75.3, O75.5, O75.82-O77.0, O80, O86.11, O86.13-O86.29, O O88.019, O O88.119, O O88.219, O O88.319, O O88.819, O90.3, O90.5-O90.89, O O90.019, O O91.119, O O91.219, O O92.019, O O92.119, O92.20-O92.3, O92.6-O92.79, O O99.73, O O9A.53, Z33.1, or Z Z or with Z with codes Z Z30.09, Z30.40-Z30.42, Z30.431, Z30.49 or Z30.9 Revised 10/19/2015 YPE Page 15

16 Description ICD9 Code Prior to 10/1/14 ICD10 Code Effective 10/1/14 Notes Sterilization 58565, 58600, 58605, 58611, 58565, 58600, 58605, 58611, Female only 58615, , 00851, 58615, , 00851, One procedure per lifetime A4264 with code A4264 with code V25.2 Z30.2 Confirmatory Test Two in a lifetime Medical Contraceptive Methods has to have a confirmatory test and with code V25.8 A4261, A4266,11981, 11983, 57170, 58300, J1055, J1056, J7307, J7300, J7302, J7303, J7304, J7306, S4981, S4989, with codes V25.02, V25.11, V25.13, V25.42, V25.43, V25.49, or V /31/12 cancel J1055 and J /01/13 add J1050 and codes V25.09, V25.40 and V has to have a confirmatory test and with code Z30.8 A4261, A4266,11981, 11983, 57170, 58300, J1055, J1056, J7307, J7300, J7302, J7303, J7304, J7306, S4981, S4989, with codes Z Z30.019, Z30.42, Z30.430, Z30.431, Z30.433, or Z /31/12 cancel J1055 and J /01/13 add J1050 and codes Z30.09, Z30.40, or Z30.9 Note: injection code if Depo-Provera was given was not added to HCR Women s Preventive Coding since we are unable to tie it back to a matching procedure to provide accurate coverage 02/20/13 add 11976, and and code V /01/13 add Q /20/13 add 11976, and and code Z /01/13 add Q /01/14 cancel Q /01/14 add J /01/14 cancel Q /01/14 add J7301 Pharmacy Contraceptive Methods Generic only Brand coverage may be available, contact Customer Service for additional information To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled by the pharmacy To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled by the pharmacy Breast Feeding Counseling and Support Three per year in conjunction with with modifier TH and code V with modifier TH and code Z39.1 E0604 is only available for high risk Revised 10/19/2015 YPE Page 16

17 Description ICD9 Code Prior to 10/1/14 ICD10 Code Effective 10/1/14 Notes birth Supplies Pumps and Accessories Screening and Counseling for Interpersonal and Domestic Violence Females only beginning at age 10 Annually Screening for Intimate Partner Violence and Abuse of Elderly and Vulnerable Adults Females only beginning at age 10 Annually Pumps - E0602, E0603 with type service H for rental or G for purchase, E0604 rental only E0604 TS H with codes V61.5, , , , , , , , , , , 770.7, , , Accessories - A4281, A4282, A4283, A4285, A with codes V61.11, V61.12, V61.21, V61.22, V62.83 Effective 2/1/ with codes V61.10, V61.11, V61.12, V61.20, V61.21, V61.22, V62.83 Pumps - E0602, E0603 with type service H for rental or G for purchase, E0604 rental only E0604 TS H with codes P P07.39, P27.0-P27.9, P29.3, P92.1-P92.9, Q20.0-Q37.9, Q38.1-Q38.3, Q90.0-Q91.7, Q93.3-Q93.9, R63.3, Z64.1 Accessories - A4281, A4282, A4283, A4285, A with codes Z Z69.12, Z69.82 Effective 2/1/ with codes Z65.9, Z Z69.12, Z69.82, Z71.89 HCP ROUTINE PRENATAL DX (ICD9) V22,V220,V221,V222, V28,V280,V281,V282,V283,V284,V285,V286,V2881,V2882,V2889,V289, V616, V617, V7242, V89, V890, V8901, V8902, V8903, V8904, V8905,V8909,64300,64303,64410,64413,64510,64513,65820,65823,67100,67103,6711,67110,67111,67113,67180,67183,67600,67603,67610,67613,67620, 67623,67630,67633,67640,67643,67650,67653,67660,67663,67680,67683,67690,67693 HCP ROUTINE PRENATAL DX (ICD10 Effective 10/1/2015) O21.0, O22.00-O22.13, O22.40-O22.43, O22.8X1-O22.8X9, O42.10-O42.119, O47.00-O48.0, O O92.019, O O92.119, O92.20-O92.3, O92.5-O92.79, Z03.71-Z03.79, Z32.01, Z33.1, Z34.00-Z36, Z64.0 HCP HIGH RISK PRENATAL DX (ICD9) V23,V230,V231,V232,V233, V234,V2341,V2342,V2349,V235,V237,V238,V2381,V2382,V2383,V2384,V2385,V2386,V2387,V2389,V239,V91,V910,V9100,V9101 V9102,V9103,V9109,V911,V9110,V9111,V9112,V9119,V912,V9120,V9121,V9122,V9129,V919,V9190,V9191,V9192,V9199,630, 631,6310,6318,632,633,6330, 63300,63301,6331,63310,63311,6332,63320,63321,6338,63380,63381,6339,63390,63391,634,6340,63400,63401,63402,6341,63410,63411,63412,6342, 63420,63421,63422,6343,63430,63431,63432,6344,63440,63441,63442,6345,63450,63451,63452,6346,63460,63461,63462,6347,63470,63471,63472, 6348,63480,63481,63482,6349,63490,63491,63492,635,6350,63500,63501,63502,6351,63510,63511,63512,6352,63520,63521,63522,6353,63530,63531, 63532,6354,63540,63541,63542,6355,63550,63551,63552,6356,63560,63561,63562,6357,63570,63571,63572,6358,63580,63581,63582,6359,63590,63591, Revised 10/19/2015 YPE Page 17

18 63592,637,6370,63700,63701,63702,6371,63710,63711,63712,6372,63720,63721,63722,6373,63730,63731,63732,6374,63740,63741,63742,6375,63750, 63751,63752,6376,63760,63761,63762,6377,63770,63771,63772,6378,63780,63781,63782,6379,63790,63791,63792,638,6380,6381,6382,6383,6384,6385, 6386,6387,6388,6389,64000,64003,6408,64080,64083,64090,64093,64100,64103,64110,64113,64120,64123,64130,64133,64180,64183,64190,64193,64200, 64203,64210,64213,64220,64223,64230,64233,64240,64243,64250,64253,64260,64263,64270,64273,64290,64293,64310,64313,64320,64323,64380, 64383,64390,64393,64400,64403,64420,64520,64523,64600,64603,64610,64613,64620,64623,64630,64633,64640,64643,64650,64653,64660, 64663,64670,64673,64680,64683,64690,64693,64700,64703,64710,64713,64720,64723,64730,64733,64740,64743,64750,64753,64760,64763,64780,64783, 64790,64793,64800,64803,64810,64813,64820,64823,64830,64833,64840,64843,64850,64853,64860,64863,64870,64873,64880,64883,64890,64893,64900, 64903,64910,64913,64920,64923,64930,64933,64940,64943,64950,64953,64960,64963,64970,64973,65100,65103,65110,65113,65120,65123,65130,65133, 65140,65143,65150,65153,65160,65163,65170,65173,65180,65183,65190,65193,65200,65203,65210,65213,65220,65223,65230,65233,65240,65243,65250, 65253,65260,65263,65270,65273,65280,65283,65290,65293,65300,65303,65310,65313,65320,65323,65330,65333,65340,65343,65350,65353,65360,65363, 65370,65373,65380,65383,65390,65393,65400,65403,65410,65413,65420,65423,65430,65433,65440,65443,65450,65453,65460,65463,65470,65473,65480, 65483,65490,65493,65500,65503,65510,65513,65520,65523,65530,65533,65540,65543,65550,65553,65560,65563,65570,65573,65580,65583,65590,65593, 65600,65603,65610,65613,65620,65623,65630,65633,65640,65643,65650,65653,65660,65663,65670,65673,65680,65683,65690,65693,65700,65703,65800, 65803,65810,65813,65840,65843,65880,65883,65890,65893,65940,65943,65950,65953,65960,65963, 67120,67123,67130,67133,67150,67153, 67190,67193, 67500,67503,67510,67513,67520,67523,67580,67583,67590,67593,67800,67803,67810,67813,67900,67903,67910,67913 HCP HIGH RISK PRENATAL DX (ICD10 Effective 10/1/2015) O00-O07.4, O09.00-O10.019, O O10.119, O O10.219, O O10.319, O O10.419, O O10.919, O11.1-O15.03, O15.9-O20.9, O21.1-O21.9, O O22.33, O22.50-O22.53, O22.90-O24.019, O O24.119, O O24.319, O O24.419, O O24.819, O O24.919, O25.10-O25.13, O26.00-O26.43, O O26.619, O O26.719, O O26.93, O O30.93, O31.00X-O32.9XX (7 th character 0,1,2,3,4,5, or 9), O33.0-O33.2, O33.3XX-O33.6XX (7 th character 0,1,2,3,4,5, or 9), O33.7-O34.93, O35.0XX-O41.93X (7 th Character 0,1,2,3,4,5, or 9), O42.00-O42.019, O42.90-O42.919, O O46.93, O48.1-O60.03, O60.10X (7 th character 0,1,2,3,4,5, or 9), O60.20X (7 th character 0,1,2,3,4,5,or 9), O O91.019, O O91.119, O O91.219, O91.23, O O98.019, O O98.119, O O98.219, O O98.319, O O98.419, O O98.519, O O98.619, O O98.719, O O98.819, O O98.919, O O99.019, O O99.119, O O99.213, O O99.283, O O99.313, O O99.323, O O99.333, O O99.343, O O99.353, O O99.419, O O99.519, O O99.619, O O99.719, O99.810, O99.820, O99.830, O O99.843, O99.89, O9A.111-O9A.119, O9A.211-O9A.219, O9A.311-O9A.319, O9A.411-O9A.419, O9A.511-O9A.519, Z33.2 The Patient Protection and Affordable Care Act (ACA) defines preventive care services as follows: Items or services recommended with an A or B rating by the U.S. Preventive Services Task Force. Immunization recommended by the Advisory Committee on Immunization Practices (ACIP) of the Center for Disease Control (CDC). (children, adolescent, and adult) Preventive care and screening for infants, children, and adolescents supported by the Health Resources and Services Administration (Bright Futures). Preventive care and screening for women supported by the Health Resources and Service Administration. (These guidelines have not been defined yet.) All providers (including those outside the state of Alabama) must use the codes provided in this document when filing claims for healthcare reform mandated preventive services for a Blue Cross and Blue Shield of Alabama member. If the preventive services section of a plan's benefit booklet refers to AlabamaBlue.com, the preventive services and immunizations in this document will be covered by the health plan. However, a group may decide to delay the effective date for coverage until the group's plan year for any new preventive services and immunizations recently added to this list. If a plan covers these services, please be aware that in some cases, routine preventive services and routine immunizations may be billed separately from an office or other facility visit. In that case, the applicable office visit or Revised 10/19/2015 YPE Page 18

19 outpatient facility copayments described in the physician benefits and outpatient hospital benefits sections of the benefit booklet may apply. In any case, applicable office visit or facility copayments may still apply when the primary purpose for a visit is not routine preventive services and/or routine immunizations. If you have any questions about a plan s benefits, you may call our Customer Service Department at the number on the back of the ID card. Revised 10/19/2015 YPE Page 19

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