Preventive Service HCPCS. Procedure Description ICD-9 Codes Modifier 33 Required? Page 1 of 6

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1 Well-Woman Exam G0101 Cervical or vaginal cancer screening; pelvic and clinical breast examination Breast Cancer V Screening mammography, bilateral (2-view film study of each breast) V Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; screening mammography (List separately in addition to code for primary procedure) V16.3 V76.11 V76.12 G0202 Screening mammography, producing direct digital image, bilateral, all views Cervical Cancer Cytopathology, cervical or vaginal screening by various methods and to report physician interpretation services G0141-G0148 Screening cytopathology smears, cervical or vaginal, performed by various methods and to report physician interpretation services V76.2 V72.31 V72.32 Chlamydia Chlamydia V Chlamydia, lgm V Culture, chlamydia, any source V22.0-V Chlamydia trachomatis Chlamydia trachomatis, direct probe technique Chlamydia trachomatis, amplified probe technique Colorectal Cancer Office or other outpatient visit for the evaluation and management of a V16.0 V18.51 V18.9 V76.41 V76.51 G0104 G0105 G0121 Colorectal cancer screening; flexible sigmoidoscopy Colorectal cancer screening; colonoscopy on individual at high risk Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) with biopsy, single or multiple with removal of foreign body with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery with control of bleeding (e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) with directed submucosal injection(s), any substance with decompression of volvulus, any method with removal of tumor(s), polyp(s), or other lesion(s) by snare technique with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique with dilation by balloon, 1 or more strictures Colonoscopy, rigid or flexible, transabdominal via colotomy, single or multiple Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure) with removal of foreign body with biopsy, single or multiple with directed submucosal injection(s), any substance with control of bleeding (e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique Page 1 of 6

2 45384 with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery Colorectal Cancer (con't) with removal of tumor(s), polyp(s), or other lesion(s) by snare technique with dilation by balloon, 1 or more strictures with transendoscopic stent placement (includes predilation) with endoscopic ultrasound examination with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s) G0328 Colorectal cancer screening; fecal occult blood test, immunoassay, 1-3 simultaneous determinations Blood, occult, by peroxidase activity (e.g., guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (i.e., patient was provided 3 cards or single triple card for consecutive collection) Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations Gonorrhea Culture, presumptive, pathogenic organisms, screening only V Smear, primary source with interpretation; Gram or Giemsa stain for bacteria, fungi, or cell types Neisseria gonorrhoeae, direct probe technique Neisseria gonorrhoeae, amplified probe technique Chlamydia trachomatis, quantification Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s) technique amplified probe(s) technique High Blood Pressure Office or other outpatient visit for the evaluation and management of a V22.0-V23.89 V81.1 HIV HTLV or HIV antibody, confirmatory test (e.g., Western Blot) V HIV-1 V22.0-V HIV HIV-1 and HIV-2, single assay G0432 Infectious agent antigen detection by enzyme immunoassay (EIA) technique, qualitative or semi-quantitative, multiple-step method, HIV-1 or HIV-2, screening G0433 G0435 Infectious agent antigen detection by enzyme-linked immunosorbent assay (ELISA) technique, antibody, HIV-1 or HIV-2, screening Infectious agent antigen detection by rapid antibody test of oral mucosa transudate, HIV-1 or HIV-2, screening Office or other outpatient visit for the evaluation and management of a new or established patient, which requires these 3 key components: A V15.89 V65.44 V65.45 V69.2 Page 2 of 6

3 Human Papillomavirus testing nfectious agent detection by nucleic acid (DNA or RNA); papillomavirus, human, direct probe technique Infectious agent detection by nucleic acid (DNA or RNA); papillomavirus, human, amplified probe technique V73.81 V76.2 V76.47 Lipid Disorders Lipid panel V Cholesterol, serum or whole blood, total Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) Syphilis Obstetric panel V22.0-V Syphilis test, non-treponemal antibody; qualitative (e.g., VDRL, RPR, ART) V69.2 V Antibody; influenza virus. Treponema pallidum. Type 2 Diabetes Mellitus Glucose; quantitative, blood (except reagent strip) V Hemoglobin; by copper sulfate method, non-automated. Glycosylated (A1C). Osteoporosis Ultrasound bone density measurement and interpretation, peripheral site(s), any method Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine) appendicular skeleton (peripheral) (e.g., radius, wrist, heel) Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine) appendicular skeleton (peripheral) (e.g., radius, wrist, heel) Radiographic absorptiometry (e.g., photodensitometry, radiogrammetry), 1 or more sites Bone density (bone mineral content) study, 1 or more sites; single photon absorptiometry G0130 Single energy x-ray absorptiometry (SEXA) bone density study, one or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel) Depression Office or other outpatient visit for the evaluation and management of a V82.81 V49.81 V79.0 Alcohol Misuse Office or other outpatient visit for the evaluation and management of a V22.0-V23.89 V65.42 V Alcohol and/or substance (other than tobacco) abuse structured screening (e.g., AUDIT, DAST), and brief intervention (SBI) services. Differences in codes are time-based. Aspirin for the prevention of Cardiovascular disease (CVD) Folic acid to prevent neural tube defects Covered through MEDCO with prescription Covered through MEDCO with prescription Page 3 of 6

4 Tobacco Use and Tobacco Caused Disease Office or other outpatient visit for the evaluation and management of a V Tobacco Use and Tobacco Caused Disease (cont) Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes G0436 G0437 Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 10 minutes Obesity Office or other outpatient visit for the evaluation and management of a V70.1 V Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes group (2 or more individual(s)) each 30 minutes S9470 Nutritional counseling, dietitian visit Healthy Diet Office or other outpatient visit for the evaluation and management of a V65.3 with one of the following additional diagnoses: Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes group (2 or more individual(s)) each 30 minutes S9452 S9470 Nutrition classes, nonphysician provider, per session Nutritional counseling, dietitian visit Page 4 of 6

5 Counseling for Sexually Transmitted Infections (STI) Office or other outpatient visit for the evaluation and management of a V15.89 V65.44 V65.45 V69.2 Contraceptive methods and Removal, implantable contraceptive capsules V25.01 counseling Insertion, non-biodegradable drug delivery implant V25.02 Contraceptive methods and counseling (con't) Removal, non-biodegradable drug delivery implant V Removal with reinsertion, non-biodegradable drug delivery implant V Diaphragm or cervical cap fitting with instructions V Insertion of intrauterine device (IUD) V Removal of intrauterine device (IUD) V 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 (separate procedure) V25.2 V25.40 V25.41 V25.42 V Ligation or transection of fallopian tube(s) when done at the time of cesarean delivery or intra-abdominal surgery (not a separate procedure) (List separately in addition to code for primary procedure) V25.49 V25.5 V Occlusion of fallopian tube(s) by device (eg, band, clip, Falope ring) vaginal or suprapubic approach Laparoscopy, surgical; with fulguration of oviducts (with or without transection) Laparoscopy, surgical; with occlusion of oviducts by device (eg, band, clip, or Falope ring) J1055 Injection, medroxyprogesterone acetate for contraceptive use, 150 mg J1056 Injection, medroxyprogesterone acetate / estradiol cypionate, 5mg / 25mg J7300 J7302 J7306 J7307 Intrauterine copper contraceptive Levonorgestrel-releasing intrauterine contraceptive system, 52 mg Levonorgestrel (contraceptive) implant system, including implants and supplies Etonogestrel (contraceptive) implant system, including implant and supplies Q0090 Levonorgestrel-releasing intrauterine contraceptive system (Skyla) 13.5 mg S4981 S4989 Insertion of levonorgestrel-releasing intrauterine system Contraceptive intrauterine device (e.g., Progestacert IUD), including implants and supplies Page 5 of 6

6 Office or other outpatient visit for the evaluation and management of a new or established patient, which requires these 3 key components: A Contraceptives available by prescription only, covered under HMSA s drug riders are processed through Medco: Contraceptive Diaphragms/Cervical Caps, Generic Oral Contraceptives, and Contraceptive Other Methods (e.g. ring and patch) Screening and counseling for interpersonal and domestic violence Various BRCA mutation testing and counseling Medical genetics and genetic counseling services, each 30 minutes face-to-face with patient/family BRCA mutation testing and S0265 Genetic counseling, under physician supervision, each 15 minutes counseling (con't) S3818 Complete gene sequence analysis; BRCA1 gene Chemoprevention of Breast Cancer S3819 S3820 S3822 S3823 Complete gene sequence analysis; BRCA2 gene Complete BRCA1 and BRCA2 gene sequence analysis for susceptibility to breast and ovarian cancer Single mutation analysis (in individual with a known BRCA1 or BRCA2 mutation in the family) for susceptibility to breast and ovarian cancer Three-mutation BRCA1 and BRCA2 analysis for susceptibility to breast and ovarian cancer in Ashkenazi individuals Office or other outpatient visit for the evaluation and management of a Precertification Required. Refer to Medical Policy V16.3 Page 6 of 6