Procedure Code(s): n/a This counseling service is included in a preventive care wellness examination or focused E&M visit.

Transcription

1 Coding Summary for Providers NOTE THE FOLLOWING: The purpose of this document is to provide a quick reference of the applicable codes for UnitedHealthcare plans that cover preventive care services in accordance with the health care reform law. This resource does not replace or supersede the Preventive Care Services Coverage Determination Guideline. If there are any differences between this summary and the Preventive Care Services Coverage Determination Guideline, then the Coverage Determination Guideline takes precedence. Certain UnitedHealthcare plans do NOT use the following codes for preventive care benefits. This document does NOT apply to all UnitedHealthcare members. Please use your existing process for benefit verification such as looking up member benefit information at: UnitedHealthcareOnline.com Codes and (where listed below) are only covered as Preventive when done for a preventive lab procedure that requires a blood draw. See the Preventive Care Services Coverage Determination Guideline for complete coding instructions.. Each member s benefits are defined by his or her benefit plan documents, and any information in the following tables that is inconsistent with the applicable benefit plan documents does not constitute an additional benefit. Benefit adjudication is contingent upon accurate claims submission by the provider, including diagnosis, procedure, age and gender. See the Preventive Care Services Coverage Determination Guideline for a listing of applicable ICD-10 diagnosis codes effective on Oct. 1, 2015 Abdominal Aortic Aneurysm Anemia, Iron Deficiency Anemia Aspirin for the Prevention of Cardiovascular Disease (Counseling) 76700, 76705, 76770, 76775, G0389 Diagnosis Code(s): V , 85014, 85018, 36415, Diagnosis Code(s): Pregnancy (see list at end of section). This counseling service is included in a preventive care wellness examination or focused E&M visit. Bacteriuria Diagnosis Code(s): Pregnancy (see list at end of section). Behavioral Counseling in Primary Care to Promote a Healthy Diet , , G0270, G0271, G0446, G0447, S Diagnosis Code(s): V77.91, V15.82, V17.3, V17.49, , , V85.41 V85.45, 272.0, 272.1, 272.2, 272.3, 272.4, 401.0, 401.1, 401.9, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Males. Age Pregnant Pregnant Effective June 1, 2014 p. 1 of 9

2 Behavioral Counseling to Prevent Sexually Transmitted Infections Cervical Cancer, Pap Smear Chemoprevention of Breast Cancer (Counseling) Chlamydia Infection Cholesterol (Lipid Disorders ) , , , , , , , , , , , , , , , , , , , , , , , , , , 440.0, 440.1, , , , , , , , , , 440.8, 440.9, , , , , , , , , G0445 Code Group 1 (payable regardless of diagnosis code): G0101, G0123, G0124, G0141, G0143 G0145, G0147, G0148, Q0091, P3000, P3001 Code Group 2 (requires a diagnosis code from list below): , 88147, 88148, 88150, , , 88174, Diagnosis Code(s) Code Group 2: V70.0, V72.31, V72.32, V , 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99385, 99386, 99387, 99395, 99396, 99397, G0463 Diagnosis Code(s): V16.3, V16.41 Diagnosis code must be in primary position , 86632, 87110, 87270, 87320, 87490, 87491, 87492, 87801, 87810, 36415, Diagnosis Code(s): V70.0, V73.88, V73.98, V74.5, V75.9, OR Pregnancy (see list at end of section) , 82465, 83718, 83719, 83721, 84478, 36415, Diagnosis Code(s) (Required for all): V70.0 or V77.91 Diagnosis Codes for increased risk for coronary heart disease (for Men 20-34, and all Women 20 and up): V15.82, V17.3, V17.49, , , V85.41 V85.45, 401.0, 401.1, 401.9, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 440.0, 440.1, , , , , , , , , , 440.8, 440.9, , , , , , , , limits. All males age 35 and up. Males age if at increased risk for coronary heart disease. Females age 20 and up if at increased risk for coronary heart disease. NOTE: These will only pay as preventive if there is no prior history of a lipid disorder. Effective June 1, 2014 p. 2 of 9

3 Colorectal Cancer Counseling and Interventions to Prevent Tobacco Use Fecal Occult Blood Testing, Sigmoidoscopy, or Colonoscopy: Code Group 1 (Preventive regardless of diagnosis code): G0104, G0105, G0106, G0120, G0121, G0122, G0328 Code Group 2 (Preventive if billed in addition to a Code Group 1 code, OR if billed with one of the Diagnosis codes below): Procedure Codes: 44388, 44389, 44392, 44393, 44394, 45330, 45331, 45333, 45338, 45339, 45378, 45380, 45381, 45383, 45384, 45385, 82270, Diagnosis Code(s) (for Code Group 2): V16.0, V18.51, V18.59, V70.0, V76.41, V76.50, V76.51 Code Group 3 (Pathology): 88304, (These are Preventive if billed with one of the listed diagnosis code from Code Group 2 PLUS one of the Procedure code from Code Group 1 or 2): Computed Tomographic Colonography (Virtual Colonoscopy): (Preventive regardless of diagnosis code): , 99406, 99407, G0436, G0437 Diabetes 82947, 82948, 82950, 82951, 82952, 83036, 36415, Diagnosis Code(s): V70.0 or V77.1, PLUS ONE OF THE FOLLOWING HYPERTENSION CODES: 401.0, 401.1, 401.9, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , See Expanded Women s Preventive Health table below for Gestational Diabetes codes. Genetic Counseling and Evaluation for BRCA Testing; and BRCA Lab Genetic Counseling and Evaluation: 96040, , , , , S0265, G0463 Diagnosis Code(s): V10.3, V10.43, V16.3, V16.41 Diagnosis code must be in primary position. BRCA Lab s: *Prior authorization requirements apply to BRCA lab screening Diagnosis Code(s): Family History: V16.3 and V16.41 This benefit only applies to patients with hypertension. NOTE: These will only pay as preventive if there is no prior history of diabetes. BRCA Lab s: Females age 18 and up with a family history of breast or ovarian cancer. Note: preventive benefits do not apply to BRCA Lab s for those that have a personal history, or current diagnosis, of breast and/or ovarian cancer. Effective June 1, 2014 p. 3 of 9

4 Gonorrhea 87590, 87591, 87592, 87801, Diagnosis Code(s): V70.0, V74.5, V75.9, OR Pregnancy (see list at end of section). Hepatitis B Virus Infection Hepatitis C Virus Infection (as of June 1, 2014) HIV Human Immunodeficiency Virus for Adolescents and Adults (Males and Females) 87340, 87341, 36415, Diagnosis Code(s): Pregnancy (see list at end of section) , 86804, 36415, Diagnosis Code(s): 042, , , , , , , , , 079.4, , , , 090.0, 090.1, 090.2, 090.3, , , , , 090.5, 090.6, 090.7, 090.9, 091.0, 091.1, 091.2, 091.3, 091.4, , , , , , 091.7, , , , 091.9, 092.0, 092.9, 093.0, 093.1, , , , , , , , , 093.9, 094.0, 094.1, 094.2, 094.3, , , , , , , , , 094.9, 095.0, 095.1, 095.2, 095.4, 095.5, 095.6, 095.7, 095.8, 095.9, 096, 097.0, 097.1, 097.9, 098.0, , , , , , , , , , 098.2, , , , , , , , , , , , , , , , , , , , 098.6, 098.7, , , , , , , , 099.0, 099.1, 099.2, 099.3, , , , , , , , , , , , 099.8, 099.9, , , , , , 131.8, 131.9, 286.0, 286.1, 286.2, 286.3, 286.4, , , , 286.6, 286.7, 286.9, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 555.0, 555.1, 555.2, 555.9, 556.0, 556.1, 556.2, 556.3, 556.4, 556.5, 556.8, 556.9, 585.3, 585.4, 585.5, 585.6, 608.4, 614.9, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 760.2, V01.6, V01.79, V02.7, V02.8, V07.39, V07.39, V08, V12.3, V15.85, V42.0, V42.1, V42.2, V42.3, V42.4, V42.5, V42.6, V42.81, V42.82, V42.83, V42.84, V42.89, V42.9, V45.11, V56.0, V56.31, V56.32, V56.8, V58.2, V59.01, V59.02, V59.09, V59.1, V59.2, V59.3, V59.4, V59.5, V59.6, V59.8, V59.9, V65.44, V69.2, V70.0, V71.5, V73.89, V73.99, V74.5, V75.9, V83.01, V83.02, V , 86701, 86702, 86703, G0432, G0433, G0435, S3645, 36415, Diagnosis Code(s): V02.9, V70.0, V73.89, V74.5, V75.9, OR Pregnancy (see list at end of section). Pregnant females. No age or frequency Immunizations Administration: 90460, 90461, 90471, 90472, 90473, 90474, G0008, G0009, G0010 Hepatitis A: 90632, 90633, 90634, 90636; Hemophilus influenza b: 90645, 90646, 90647, 90648; HPV: 90649, ; Influenza virus: 90654, 90655, 90656, 90657, 90658, 90660, 90661, 90662, 90664, 90666, 90667, 90668, 90672,90673, 90685, 90686, 90688, Q2034, Q2035, Q2036, Q2037, Q2038, Q2039; Effective June 1, 2014 p. 4 of 9 Preventive benefits are applied to immunizations that are within the ages listed (if any) in the FDA

5 Major Depressive Disorder in Children and Adolescents () Pneumococcal conjugate: 90669, 90670, S0195; Rotavirus: 90680, 90681; Dtap / Dtpap-IPV, Dtap-Hib-IPV / DTP / DT / Tetanus / Polio / TdaP/ Measles, Mumps, Rubella / MMR: 90696, 90698, 90700, 90702, 90703, 90704, 90705, 90706, 90707, 90708, 90710, 90713, 90714, 90715, 90719, 90720, 90721, 90723; Varicella: 90716; Pneumococcal: 90732; Meningococcal: 90733, 90734, 90644; Zoster: 90736; Hepatitis B: 90740, 90743, 90744, 90746, 90747, Revenue Code: , G0444 Diagnosis Code(s): V79.0 (Required for only) Also see section below: for Depression in Adults approval, or, ACIP recommendations. See the Preventive Care Services Coverage Determination Guideline for details. Metabolic Panel S3620, 82017, 82136, 82261, 82775, 83020, 83498, 83516, 84030, 84437, 84443, 36415, Age 0 90 days. Newborn s Hearing : V5008, 92551, 92558, Hypothyroidism : 84437, 84443, 36415, Phenylketonuria : S3620, 84030, 36415, Sickle Cell : S3850, 83020, 83021, 83030, 83033, 83051, 36415, Osteoporosis 76977, 77078, 77080, 77081, G0130 Diagnosis Code(s): V17.81, V70.0, V82.81 Prevention of Dental Caries in Preschool Children (Counseling) Primary Care Interventions to Promote Breastfeeding This service is included in the payment for a Preventive Care visit. This service is included in primary care or OB/GYN office visits. Also see Expanded Women s Preventive Care table below. Age 0 90 days. Prevention of Falls in Community-Dwelling Older Adults This service is included in the payment for a Preventive Care visit or focused E&M visit. Prostate Cancer Code Group 1: G0102, G0103, 36415, Code Group 2 (requires diagnosis code): 84152, 84153, 84154, 36415, Diagnosis Code(s): Code Group 1: Code Group 2: V16.42, V70.0, V76.44 Males, age 40 and up. Effective June 1, 2014 p. 5 of 9

6 RH Incompatibility 86901, 36415, Diagnosis Code(s): Pregnancy (see list at end of section). Pregnant females. Rubella By History of Vaccination or by Serology and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse for Depression in Adults History of Vaccination: No codes (included in exam) Serology: 86762, 36415, Diagnosis Code(s): V70.0 or V , 99409, G0442, G , G0444 Diagnosis Code(s): V79.0 (Required for only) Also see section above: Major Depressive Disorder in Children and Adolescents () for High Blood Pressure for Intimate Partner Violence This service is included in a preventive care wellness examination or focused E&M visit. This service is included in a preventive care wellness exam. for Obesity in Adults for Obesity in Children and Adolescents for Visual Impairment in Children 97802, 97803, 97804, 99401, 99402, 99403, 99404, G0446, G0447 Diagnosis Code(s) (Required for and ): BMI 30+ and Obesity: V85.30 V85.39, V85.41 V85.45, , , 97803, 97804, 99401, 99402, 99403, 99404, G0446, G0447 Diagnosis Code(s) (Required for and ): Obesity: , , Children less than age 5. Mammography G0202, 77052, 77057; Revenue code: 0403 Syphilis 86592, 86593, 36415, Diagnosis Code(s): V70.0, V74.5, V74.9, V75.9 OR Pregnancy (see list at end of section). Wellness Examinations (well baby, well child, well adult) G0402, G0438, G0439, G0445, S0610, S0612, S0613, , , , , Effective June 1, 2014 p. 6 of 9

7 Bright Futures: Anemia in Children Developmental/Autism Dyslipidemia Hearing Tests Lead TB Testing Cancer s: 85014, 85018, 36415, Diagnosis Code(s): V20.2, V20.31, V20.32, V Diagnosis Code(s): V , 82465, 83718, 83719, 83721, 84478, 36415, Diagnosis Code(s): V20.2, V , 92552, Diagnosis Code(s): V20.2, V , 36415, Diagnosis Code(s): V20.2, V , Diagnosis Code(s): , , V20.2. V74.1 CPT code is only payable as preventive with diagnosis code , or V74.1 Ages 24 months to 21 years. * The following is a list of preventive cancer screenings. These are also listed above. Cervical Cancer, Pap Smear Colorectal Cancer Code Group 1 (payable regardless of diagnosis code): G0101, G0123, G0124, G0141, G0143 G0145, G0147, G0148, Q0091, P3000, P3001 Code Group 2 (requires a diagnosis code from list below): , 88147, 88148, 88150, , , 88174, Diagnosis Code(s) Code Group 2: V70.0, V72.31, V72.32, V76.2 Fecal Occult Blood Testing, Sigmoidoscopy, or Colonoscopy: Code Group 1 (Preventive regardless of diagnosis code): G0104, G0105, G0106, G0120, G0121, G0122, G0328 Code Group 2 (Preventive if billed in addition to a Code Group 1 code, OR if billed with one of the Diagnosis codes below): Procedure Codes: 44388, 44389, 44392, 44393, 44394, 45330, 45331, 45333, 45338, 45339, 45378, 45380, 45381, 45383, 45384, 45385, 82270, Diagnosis Code(s) (for Code Group 2): V16.0, V18.51, V18.59, V70.0, V76.41, V76.50, V76.51 Code Group 3 (Pathology): 88304, (These are Preventive if billed with one of the listed diagnosis code from Code Group 2 PLUS one of the Procedure code from Code Group 1 or 2). Computed Tomographic Colonography (Virtual Colonoscopy) (Preventive regardless of diagnosis code): limits. Effective June 1, 2014 p. 7 of 9

8 Prostate Cancer Mammography Code Group 1: G0102, G0103, 36415, Code Group 2: (requires diagnosis code): 84152, 84153, 84154, 36415, Diagnosis Code(s): Code Group 1: Code Group 2: V16.42, V70.0, V76.44 G0202, 77052, 77057; Revenue code: 0403 Males, age 40 and up. Pregnancy Diagnosis Code List: The following codes are required only where indicated in the Preventive Care Services table (above), or in the Expanded Women s Preventive Care Services table (below): V22.0 V22.2 V23.0 V23.3, V23.41, V23.42, V23.49, V23.5, V23.7, V23.81 V23.86, V23.87, V23.89, V23.9 V91.00 V91.03, V91.09, V91.10 V91.12, V91.19 V91.22, V91.29, V91.90 V91.92, V91.99 Expanded Women s The following benefits are effective beginning the first plan year on or after 8/1/12. Code(s): Well-Woman Visits Also see Wellness Well-woman visits: See the Wellness Examinations section above. Examinations section Prenatal Office Visits: ; ; 99078, G0463 in the Preventive Care Prenatal Care Visits: 59425, Services table above. Global Obstetrical Codes*: 59400, 59510, 59610, * The routine, low-risk, prenatal visits portion of the Global Obstetrical code is covered as preventive. Diagnosis Code(s): See Pregnancy Diagnosis Code list above. for Gestational Diabetes 82947, 82948, 82950, 82951, 82952, 83036, 36415, Diagnosis Code(s): See Pregnancy Diagnosis Code list above. Pregnant females. Human Papillomavirus DNA Testing Counseling for Sexually Transmitted Infections Counseling and for Human Immune-deficiency Virus Contraceptive Methods (Including Diagnosis Code(s): V70.0, V72.31, V73.81, or V76.2 See the Wellness Examinations section of the Preventive Care Services table above. Counseling: See the Wellness Examinations section of the Preventive Care Services table above. Tests: See the HIV Human Immunodeficiency Virus for Adolescents and Adults section of the Preventive Services table above. Code Group 1: 58565, 58600, 58605, 58611, 58615, 58670, 58671, A4264, 57170, A4261, A4266, J7300, J7301 Effective June 1, 2014 p. 8 of 9 Females age 30 +

9 Expanded Women s The following benefits are effective beginning the first plan year on or after 8/1/12. Code(s): Sterilizations) NOTE: Certain health plans may qualify for an exemption from covering contraceptive methods and sterilizations. Breastfeeding Support, Supplies, and Counseling and Counseling for Interpersonal and Domestic Violence Code Group 2: (requires a diagnosis from list below): 11976, 11981, 11982, 11983, 58300, 58301, J1050, J7302, J7306, J7307, S4981, S4989 Code Group 2a: (Preventive when billed with J1050 AND one of the Code Group 2 Diagnosis Codes below): Code Group 2 Diagnosis Code(s): V25.01, V25.02, V25.03, V25.09, V25.11, V25.12, V25.13, V25.40, V25.41, V25.42, V25.43, V25.49, V25.5, V25.8, V25.9 Code Group 3: (requires diagnosis V25.2): 00851, 00940, 00942, 00950, 00952, 01960, 01961, 01965, 01966, 01967, Code Group 3 Diagnosis Code: V25.2 Code Group 4: (Tubal ligation followup hysterosalpingogram): 58340, Code Group 4 Diagnosis Code: V26.51 Support and Counseling: S9443, , , (Also see the codes in the Wellness Examinations section of the Preventive Care Services table above.) Diagnosis Code(s): V24.1 (Code V24.1 is required for , , and ) Equipment & Supplies: (Purchase of a personal-use electric breast pump) E0603, A4281, A4282, A4283, A4284, A4285, A4286 Diagnosis Code(s): Pregnancy diagnosis (see list above) or V24.1 See the Wellness Examinations section of the Preventive Care Services table above. Diagnosis Code(s): See the Wellness Examinations section of the Preventive Care Services table above. One pump per birth. N/A Effective June 1, 2014 p. 9 of 9