Well-Woman Exam G0101 Cervical or vaginal cancer screening; pelvic and clinical breast examination Breast Cancer V72.31 77057 Screening mammography, bilateral (2-view film study of each breast) V10.3 77052 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 88141-88175 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 86631 Chlamydia V73.88 86632 Chlamydia, lgm V73.98 87110 Culture, chlamydia, any source V22.0-V23.89 87270 Chlamydia trachomatis 87490 Chlamydia trachomatis, direct probe technique 87491 Chlamydia trachomatis, amplified probe technique Colorectal Cancer 99201-99215 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 45330 Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) 45331 with biopsy, single or multiple 45332 with removal of foreign body 45333 with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery 45334 with control of bleeding (e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) 45335 with directed submucosal injection(s), any substance 45337 with decompression of volvulus, any method 45338 with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 45339 with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique 45340 with dilation by balloon, 1 or more strictures 45355 Colonoscopy, rigid or flexible, transabdominal via colotomy, single or multiple 45378 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) 45379 with removal of foreign body 45380 with biopsy, single or multiple 45381 with directed submucosal injection(s), any substance 45382 with control of bleeding (e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) 45383 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
45384 with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery Colorectal Cancer (con't) 45385 with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 45386 with dilation by balloon, 1 or more strictures 45387 with transendoscopic stent placement (includes predilation) 45391 with endoscopic ultrasound examination 45392 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 82270 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) 82274 Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations Gonorrhea 87081 Culture, presumptive, pathogenic organisms, screening only V74.5 87205 Smear, primary source with interpretation; Gram or Giemsa stain for bacteria, fungi, or cell types 87590 Neisseria gonorrhoeae, direct probe technique 87591 Neisseria gonorrhoeae, amplified probe technique 87492 Chlamydia trachomatis, quantification 87800 Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s) technique 87801 amplified probe(s) technique High Blood Pressure 99201-99215 Office or other outpatient visit for the evaluation and management of a V22.0-V23.89 V81.1 HIV 86689 HTLV or HIV antibody, confirmatory test (e.g., Western Blot) V73.89 86701 HIV-1 V22.0-V23.89 86702 HIV-2 86703 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 99201-99215 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
Human Papillomavirus testing 87620 nfectious agent detection by nucleic acid (DNA or RNA); papillomavirus, human, direct probe technique 87621 Infectious agent detection by nucleic acid (DNA or RNA); papillomavirus, human, amplified probe technique V73.81 V76.2 V76.47 Lipid Disorders 80061 Lipid panel V77.91 82465 Cholesterol, serum or whole blood, total 83718 Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) Syphilis 80055 Obstetric panel V22.0-V23.89 86592 Syphilis test, non-treponemal antibody; qualitative (e.g., VDRL, RPR, ART) V69.2 V74.5 86780 Antibody; influenza virus. Treponema pallidum. Type 2 Diabetes Mellitus 82947 Glucose; quantitative, blood (except reagent strip) V77.1 83036 Hemoglobin; by copper sulfate method, non-automated. Glycosylated (A1C). Osteoporosis 76977 Ultrasound bone density measurement and interpretation, peripheral site(s), any method 77078 Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine) 77079 appendicular skeleton (peripheral) (e.g., radius, wrist, heel) 77080 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine) 77081 appendicular skeleton (peripheral) (e.g., radius, wrist, heel) 77083 Radiographic absorptiometry (e.g., photodensitometry, radiogrammetry), 1 or more sites 78350 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 99201-99215 Office or other outpatient visit for the evaluation and management of a V82.81 V49.81 V79.0 Alcohol Misuse 99201-99215 Office or other outpatient visit for the evaluation and management of a V22.0-V23.89 V65.42 V79.1 291.0-291.5 303.00-303.93 305.00-305.03 99408-99409 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
Tobacco Use and Tobacco Caused Disease 99201-99215 Office or other outpatient visit for the evaluation and management of a V15.82 305.1 Tobacco Use and Tobacco Caused Disease (cont) 99406 Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes 99407 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 99201-99215 Office or other outpatient visit for the evaluation and management of a V70.1 V77.1 278.00 278.01 97802 Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes 97803 re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes 97804 group (2 or more individual(s)) each 30 minutes S9470 Nutritional counseling, dietitian visit Healthy Diet 99201-99215 Office or other outpatient visit for the evaluation and management of a V65.3 with one of the following additional diagnoses: 250.00-250.93 401.0-401.9 272.0-272.9 97802 Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes 97803 re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes 97804 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
Counseling for Sexually Transmitted Infections (STI) 99201-99215 Office or other outpatient visit for the evaluation and management of a V15.89 V65.44 V65.45 V69.2 Contraceptive methods and 11976 Removal, implantable contraceptive capsules V25.01 counseling 11981 Insertion, non-biodegradable drug delivery implant V25.02 Contraceptive methods and counseling (con't) 11982 Removal, non-biodegradable drug delivery implant V25.03 11983 Removal with reinsertion, non-biodegradable drug delivery implant V25.04 57170 Diaphragm or cervical cap fitting with instructions V25.09 58300 Insertion of intrauterine device (IUD) V25.11 58301 Removal of intrauterine device (IUD) V25.13 58600 Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral 58605 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 V25.43 58611 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 V25.8 58615 Occlusion of fallopian tube(s) by device (eg, band, clip, Falope ring) vaginal or suprapubic approach 58670 Laparoscopy, surgical; with fulguration of oviducts (with or without transection) 58671 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
99201-99215 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 96040 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 99201-99215 Office or other outpatient visit for the evaluation and management of a Precertification Required. Refer to Medical Policy V16.3 Page 6 of 6