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PREVENTIVE CARE SERVICES
The following is a list of preventive services (HCP rider) along with the diagnoses and procedure codes that your health plan has determined to meet and in some situations exceed the requirements and recommendations issued by the Affordable Care Act. Your Health Plan will process these claims in a manner that is intended to comply with Section 1557 of the Affordable Care Act. Preventive services are still subject to medical management criteria.
Some or all of the contraceptives methods or prescription drugs listed may not be covered under your health 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 |
CODING |
NOTES |
ABDOMINAL AORTIC ANEURYSM, SCREENING
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76706 with diagnosis Z13.6, Z72.0, Z87.891, or F17.200-F17.219, F17.290-F17.299 |
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ALCOHOL MISUSE SCREENING AND BEHAVIORAL COUNSELING INTERVENTIONS
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G0442 and G0443 with diagnosis Z13.89, or F10.10, F10.11, F10.120, F10.129, F10.130, F10.139, Z13.39 10/1/22 add F10.90, F10.91 |
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ASPIRIN FOR THE PREVENTION OF CARDIOVASCULAR DISEASEFor dates of service prior to April 1, 2023
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For dates of service prior to April 1, 2023 99401, 99386, 99387, 99396, or 99397, G0446 with diagnosis Z13.6 or Z76.89 |
For dates of service 4/1/23 and after, this service will no longer be considered under preventive.
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ASPIRIN USE TO PREVENT PREECLAMPSIA AND RELATED MORBIDITY AND MORTALITY: PREVENTIVE MEDICATIONFor dates of service prior to April 1, 2023
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To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy | |
ASYMPTOMATIC BACTERIURIA IN PREGNANT WOMEN, SCREENING
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87081, 87084, 87086, or 87088 with a routine prenatal or high risk prenatal diagnosis code |
See end of document for a list of routine and high-risk prenatal diagnosis codes |
BREAST AND OVARIAN CANCER SUSCEPTIBILITY, GENETIC RISK ASSESSMENT AND BRCA MUTATION TESTING
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Counseling: 96040 or 99401-99404 with diagnosis Z15.01, Z15.02, Z31.5, Z71.83, Z80.3, Z80.41, Z85.3 or Z85.43 Genetic Testing: 81163, 81164, 81165, 81166, 81167, 81212, 81215, 81216, and 81217 with diagnosis Z15.01, Z15.02, Z31.5, Z71.83, Z80.3, Z80.41, Z85.3 or Z85.43 OR 81162 and 81212 with diagnosis Z15.01, Z15.02, Z31.5, Z71.83, Z80.3, Z80.41, Z85.3 or Z85.43 |
Combined with chemo prevention of breast cancer
|
BREAST CANCER PREVENTION MEDICATION
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To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy. |
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BREASTFEEDING, BEHAVIORAL INTERVENTIONS TO PROMOTE
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99401 must have modifier TH and diagnosis O09.00-O09.93, O09.A0-O09.A3, O36.80X0-O36.80X9, Z33.1, Z33.3, Z34.00-Z34.93 or Z39.1 |
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CERVICAL CANCER, SCREENING (PAP SMEAR)
|
88141, 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88155, 88164, 88165, 88166, 88167, 88174, 88175, G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001, or Q0091 with routine diagnosis |
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CHEMOPREVENTION OF BREAST CANCER
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99401 or 99402 with diagnosis code Z80.3 or Z15.01 |
Combined with BRCA benefit above |
CHLAMYDIA INFECTION, SCREENING
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87110, 87270, 87320, 87490, 87491, 87492, or 87810 with routine diagnosis except Z11.3 (see STI Screening) OR 87800, 86631, 86632 with diagnosis Z11.8
87110, 87270, 87320, 87490, 87491, 87492, or 87810 with routine diagnosis OR 86631, 86632 with diagnosis Z11.8 10/24/22 remove code 87800 |
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ROUTINE CHOLESTEROL (LIPID DISORDERS IN ADULTS), SCREENING
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80061, 82465, 83718, 83721, 84478 with routine diagnosis |
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COLORECTAL CANCER, SCREENING
Pre-Screening Consultation Effective 1/1/16
Effective 5/18/21
Colonoscopy
Effective 5/18/21
Includes outpatient facility services, physician services, and anesthesia.
Bowel Prep Medications Effective 7/1/16
Effective 5/18/21
Sigmoidoscopy
Effective 5/18/21
Barium Enema Part of standard COL
Effective 5/18/21
Fecal Occult Blood Testing (FOBT)
Effective 5/18/21
FIT-DNA (Cologuard™) Effective 11/1/2017
Effective 5/18/21
CT Colonography (Visual Colonoscopy) Effective 11/1/18
Effective 5/18/21
|
Same as COL rider
99386 or 99387 with diagnosis code Z12.11
Colonoscopy (with routine diagnosis) G0121, G0105, G6019, G6020, G6021, G6024, G6025, 44388, 44389, 44390, 44391, 44392, 44393, 44394, 44401, 44402, 44404, 44405, 44406, 44407, 45378, 45379, 45380, 45381, 45382, 45384, 45385, 45386, 45389, 45391, 45392 or 45399. 12/31/14 remove codes 44393, 44397, 45355, 45383, 45387 1/1/15 add codes 44401, 44402, 44404, 44405, 44406, 44407, 45388, 45389, G6019, G6020, G6024. G6025 1/1/16 remove codes G6019, G6020, G6021, G6024, G6025
Anesthesia 00810,99143-99145,99148-99150 With routine diagnosis
12/31/16 CANCEL 99143, 99144, 99145, 99148, 99149, 99150 1/1/17 ADD 99151, 99152, 99153, 99155, 99156, 99157, G0500 12/31/17 DELETE 00810 01/01/18 ADD 00812, 00811, 00813
Bowel Prep Medications
(GPIs: 46992004302120, 46992004302130, 46992004302140 (MSC=Y) only)
Sigmoidoscopy G0104 or 45330 with routine diagnosis
1/1/16 add 45331, 45332, 45333, 45334, 45335, 45338, 45346, 45340, 45341, 45342, 45347
Barium Enema G0106, G0120, G0122, or 74280 with routine diagnosis
Fecal Occult Blood Testing (FOBT) G0107, G0328, G0394, 82270, 82272, or 82274 with routine diagnosis
FIT-DNA (Cologuard™) 81528 with routine diagnosis
CT Colonography (Visual Colonoscopy) 74263 with routine diagnosis |
exams of biopsy(-ies) specimens (including polyps(s)) collected during a colonoscopy or sigmoidoscopy completed on the same date of service will also process without cost-sharing.
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 first-degree 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 diagnosis of clinically significant colorectal adenomas or cancer, the patient will be followed by a surveillance regimen and recommendations for screening are no longer applicable. |
CONGENITAL HYPOTHYROIDISM, SCREENING
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84436, 84437, 84439, or 84443 with diagnosis Z13.29 |
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DENTAL CARIES IN CHILDREN FROM BIRTH THROUGH AGE 5 YEARS, PREVENTION OF
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CPT 99188 with Z29.3
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DENTAL CARIES IN PRESCHOOL CHILDREN, PREVENTION |
Included in preventive office visit |
Per AAP’s Bright Futures Guidelines, this recommendation refers to the anticipatory guidance for oral health as an integral part of comprehensive patient counseling in the primary care setting. |
DEPRESSION, ANXIETY, AND SUICIDE RISK SCREENING
Effective 1/1/2023
Effective 11/1/2023
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G0444, 96127 with diagnosis Z13.31 or Z13.32 1/1/2023 add Z13.39
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DEVELOPMENTAL SCREENING
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G0451 or 96110 with a routine diagnosis code |
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DEVELOPMENTAL SURVEILLANCE FOR CHILDREN |
Included as part of an office visit |
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DEVELOPMENTAL/BEHAVIORAL ASSESSMENT – ALCOHOL AND DRUG
Effective 7/1/2021
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G2011, G0396, G0442, G0443, or H0001 with diagnosis Z72.0, Z72.89, Z72.9, or Z73.9, Z13.89
7/01/2021 add 99408; removed Z72.0, Z72.89, Z72.9, or Z73.9, Z13.89. No specific diagnosis required
|
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DYSLIPIDEMIA SCREENING
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80061 with diagnosis Z13.220 |
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DIET COUNSELING, BEHAVIORAL COUNSELING IN PRIMARY CARE TO PROMOTE A HEALTHY DIET
Effective 1/1/2021
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97802-97804, G0270, G0271, G0446, G0447 with diagnosis Z71.3, A18.84, E08.00-E13.9, E66.01-E66.1, E66.8, E66.9, I10-I22.9, I16.0, I16.1, I16.9, I21.9, I21.A1, I21.A9, I24.0-I25.9, I42.0-I43, I50.1-I50.9, I51.5-I51.7, I51.9, I52, N26.2, O24.011-O24.33, O24.811-O24.93, O99.210-O99.215, or Z68.30-Z68.45 1/13/2021 add E78.00, E78.01, E78.1, E78.2, E78.3, E78.41, E78.49, E78.5, E78.6, E88.81, R03.0 10/1/22 add I20.2, I25.112, I25.702, I25.712, I25.722, I25.732, I25.752, I25.762, I25.792 10/1/23 Remove E88.81. Add E88.810, E88.811, E88.818, E88.819, I20.81, I20.89, I21.B, I24.81, I24.89, I25.85 |
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GONORRHEA, SCREENING
(Ages 11-21 included in STI screening)
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87590, 87591, 87850, 87800 or 87801 with diagnosis Z11.3 10/24/22 Remove 87800, 87801 |
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GONORRHEA, PROPHYLACTIC MEDICATION, NEWBORN |
No code available-usually administered as an ancillary charge while inpatient at time of delivery |
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HEALTHY WEIGHT AND WEIGHT GAIN IN PREGNANCY, COUNSELINGEffective 6/1/22
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99401-99404 with a routine prenatal diagnosis code, high risk prenatal diagnosis code | |
HEMATOCRIT OR HEMOGLOBIN
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85013, 85014 or 85018 with diagnosis Z13.0
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HEPATITIS B VIRUS INFECTION IN PREGNANCY, SCREENING FOR
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87340 with diagnosis O09.00-O09.93, O36.80X0-O36.80X9, Z33.1, Z33.3, or Z34.00-Z34.93
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HEPATITIS B VIRUS INFECTION IN NONPREGNANT ADOLESCENTS AND ADULTS, SCREENING FOR
Effective 1/1/2023
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G0499, 86704, 86705, 86706, 87340 or 87341 with diagnosis 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
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HEPATITIS C VIRUS (HCV) INFECTION, SCREENING
Effective 4/1/2021
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86803, 86804, G0472 with:
Effective 4/1/2021
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HIGH BLOOD PRESSURE, SCREENING
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Usually included as part of an office visit
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HIGH BLOOD PRESSURE SCREENING (OUTSIDE OF THE CLINICAL SETTING)Ambulatory Blood Pressure Monitoring:
Self-Measured Blood Pressure Monitoring:
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Ambulatory Blood Pressure Monitoring: 93784 OR 93786, 93788, 93790 with diagnosis R03.0
Self-Measured Blood Pressure Monitoring: 99473-99474 with diagnosis R03.0
|
NOTE: Do not report ambulatory BP monitoring in the same calendar month as self-measure BP. |
HIV SCREENING
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86701, 87535, 87534, 87389, 87390, 86703, 87806, G0432, G0433, G0435, G0475 with diagnosis Z11.4 |
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HUMAN PAPILLOMAVIRUS (HPV)
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0500T, G0476, 87623, 87624, or 87625 with routine diagnosis |
Effective 9/1/2017, members will be allowed one additional service of 87625 as reflex testing if code 87624 result is documented as positive by the provider. This recommendation is response to guidelines published by The American College of Obstetricians and Gynecologists (ACOG), Number 168, October 2016 |
IMMUNIZATIONS |
Routine Immunizations – Standard PMD Contracts
|
Routine Immunizations-Coverage is based on CDC’s Advisory Committee in Immunization Practices (ACIP) recommendations regarding age, frequency, and dosage. Refer to the CDC website to view the schedules: cdc.gov/vaccines/schedules/index.html |
INPATIENT NEWBORN CARE
|
Inpatient physician services only
99221-99223, 99231-99233, 99234-99236, 99238, 99239, 99460, 99462-99464, 99478-99480 with a routine diagnosis |
|
IRON DEFICIENCY ANEMIA, PREVENTION |
Pharmacy Benefit |
|
IRON DEFICIENCY ANEMIA, SCREENING
|
85013, 85014, 85018, 85025, OR 85027 with diagnosis O09.00-O09.93, O36.80X0-O36.80X9, Z33.1, Z33.3, OR Z34.00-Z34.93 |
|
LEAD SCREENING
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83655 with diagnosis Z13.88 |
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LUNG CANCER, SCREENING WITH LOW-DOSE COMPUTED TOMOGRAPHY
Effective 3/22/2021
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71271 with Z12.2 AND Z87.891, F17.210, F17.211, F17.213, F17.218 OR F17.219 |
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MAMMOGRAPHY (BREAST CANCER SCREENING)
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77063, 77065, 77066, or 77067 with routine diagnosis | |
NOTE: When submitted with a preventive/routine code AND in conjunction with the screening mammography code, 77063 should process per HCP with no cost sharing. | ||
MATERNAL DEPRESSION SCREENING
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96161 with routine diagnosis
|
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NEWBORN METABOLIC/HEMOGLOBIN SCREENING
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S3620 with no specific diagnosis required |
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NEWBORN SCREENING PANEL
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83498 or 83788 with Z13.21, Z13.228, Z13.29 83020 with Z13.0 82261 with Z13.21, Z13.228, Z13.29 83516 with Z13.228 82776 with Z13.228 86355 or 86359 with Z13.21, Z13.228, Z13.29 82760 with Z13.228 82759 with Z13.228 86359 with Z13.21, Z13.228, Z13.29 83789 with Z13.228 |
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OBESITY IN ADULTS AND CHILDREN SCREENING
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99401, G0447 with diagnosis Z13.89, Z68.53, Z68.54 |
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ORAL HEALTH
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96160 with Z13.84 |
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OSTEOPOROSIS IN POSTMENOPAUSAL WOMEN SCREENING
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77080 with diagnosis E05.00-E05.91, E10.10-E10.9, E23.6, E28.310- E28.39 E44.0-E46, E64.0, E89.40, E89.41, F10.20-F10.220, F10.229, F17.200-F17.299, K70.0-K70.40, K70.9, K73.0-K74.69, K75.4, K75.81, K76.0, K76.89, K76.9, K90.0-K90.49, K90.89, K90.9, K91.2, M05.00-M06.9, M08.00- M08.9A, M12.00-M12.09, M45.0-M45.9, M48.8X1-M48.8X9, Q78.0, Q96.0-Q96.9, Z13.820, Z71.41, Z72.0, Z82.62, Z86.39, Z87.310-Z87.312, Z87.81, Z90.721- Z90.79, or Z92.241 10/1/21 added M45.A0, M45.A1, M45.A2, M45.A3, M45.A4, M45.A5, M45.A6, M45.A7, M45.A8, M45.AB |
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ASPIRIN (OVER–THE–COUNTER)For dates of service 4/1/23 and after, this service will no longer be considered under preventive.
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To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy. | For dates of service 4/1/23 and after, this service will no longer be considered under preventive. |
CONTRACEPTIVE METHODS
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To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy. | |
FLUORIDE (OVER–THE–COUNTER)
|
To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy. | |
FOLIC ACID (OVER–THE–COUNTER)
|
To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy. | |
IRON SUPPLEMENTS (OVER–THE–COUNTER)
|
To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy. | |
PHENYLKETONURIA SCREENING (PKU)
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84030 with diagnosis Z13.228
|
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PROSTATE SPECIFIC ANTIGEN (PSA)
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G0103 or 84153 with routine diagnosis
|
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RH (D) INCOMPATIBILITY, SCREENING
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86901 with diagnosis O09.00-O09.93, O36.80X0-O36.80X9, Z33.1, Z33.3, or Z34.00-Z34.93 |
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PREECLAMPSIA SCREENING
|
Included in prenatal office visit |
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Prenatal Conference
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CPT codes 99202-99203 or 99211-99213 with diagnosis Z76.81 |
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PREVENTION OF FALLS
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97110, 97112, 97116, G0151, or G0159 with diagnosis Z91.81, limited to 40 services each calendar year (= 10 hours of physical therapy) OR 97150 with diagnosis Z91.81, limited to 10 services each calendar year OR S9131 with diagnosis Z91.81, limited to 10 services each calendar year |
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PREVENTION OF HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTION: PRE-EXPOSURE |
To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy. Effective 9/17/2021
7/1/22 Removed J3490. Add J0739 10/24/22 Removed 87800, 87801 5/22/23 Removed Z51.81 and Z79.899 from E/M Office Visits 10/1/23 Add Z29.81 1/1/24 Add G0011, G0012, G0013 |
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PREVENTIVE HISTORY AND PHYSICAL EXAMINATIONS
|
G0101, G0102, G0438, G0439, G0463, G0513, G0514, S0612, S0613, 99202 - 99215, 99241 - 99245, 99381 - 99387, 99391 - 99397 |
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PSYCHOSOCIAL/BEHAVIORAL ASSESSMENT
|
96127 with routine diagnosis |
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HEARING, SENSORY SCREENING
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92551, 92552, 92558, 92567, 92587, 92650, 92651 or V5008 with diagnosis Z00.121, Z00.129, Z01.10, Z01.118 or Z13.5 |
|
HEARING, NEWBORN SCREENING
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92558, 92587, 92650, 92651 with diagnosis Z00.110, Z00.111, Z00.121, Z00.129, Z01.10, Z01.118, Z13.5 |
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SEXUALLY TRANSMITTED INFECTIONS, BEHAVIORAL COUNSELING INTERVENTIONS TO PREVENT
|
99401, 99402, G0445 with diagnosis Z71.89, Z72.51, Z72.52 OR Z72.53 OR 99403, 99404, G0445 with diagnosis Z71.7, Z71.89, Z72.51, Z72.52, OR Z72.53
|
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SEXUALLY TRANSMITTED INFECTIONS (STI), SCREENING
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86631, 86632, 86701, 86703, 87081, 87110, 87205, 87210, 87270, 87320, 87490, 87491, 87563, 87590, 87591, 87810, or 87850 with diagnosis Z11.3 10/24/2022 remove code 87800 |
|
SICKLE CELL DISEASE SCREENING
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83020 or 83021 with diagnosis Z13.0 |
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SKIN CANCER, BEHAVIORAL COUNSELING TO PREVENT
|
Included in E&M and/or preventive office visits |
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STATIN USE FOR THE PRIMARY PREVENTION OF CARDIOVASCULAR DISEASE IN ADULTS
|
To be considered under the Pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy |
Generic Pravastatin and Lovastatin are included products |
SYPHILIS INFECTION SCREENING
|
86592 or 86780 with diagnosis Z11.3
|
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SUDDEN CARDIAC ARREST AND SUDDEN CARDIAC DEATH SCREENINGEffective 1/1/23
|
Included in E&M and/or preventive office visits | |
TOBACCO USE AND TOBACCO-CAUSED DISEASE COUNSELING
Pregnant Females
|
99406, 99407 diagnosis F17.200-F17.299, or Z72.0 Pregnant Females 99406 or 99407 with diagnosis O99.330-O99.333 |
|
TOBACCO USE AND TOBACCO-CAUSED DISEASE, MEDICATION
|
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-the-counter medications) for a 90-day treatment regimen when prescribed by a health care provider without prior authorization. |
TYPE 2 DIABETES MELLITUS IN ADULTS, SCREENING
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82947 OR 83036 with diagnosis Z13.1, Z86.32 |
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TUBERCULIN TEST
|
86580 with diagnosis Z11.1 |
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TUBERCULOSIS INFECTION, LATENT, IN ADULTS, SCREENING FOR
|
86580, 86480, OR 86481 with diagnosis Z11.1, Z11.7
|
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UNHEALTHY DRUG USE SCREENING (ADULTS)
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G0396, G2011, H0001 or 99408 | |
URINARY INCONTINENCE, SCREENING
|
Included in E&M and/or Preventive office visits |
|
VISUAL ACUITY SCREENING IN CHILDREN
|
99173, 99174, 99177 with diagnosis Z00.110, Z00.111, Z01.00, Z00.129, Z00.121, Z01.01 or Z13.5 |
|
WOMEN’S PREVENTIVE SCREENINGS
DESCRIPTION |
CODING |
NOTES |
WELL WOMAN PREVENTIVE OFFICE VISITS
|
CPT codes 99383-99387, G0438, or S0610 with diagnosis Z00.00 or Z00.01 – limited to 1 per calendar year CPT codes 99383-99387, G0438, or S0610 with diagnosis Z01.411 or Z01.419 – limited to 1 per calendar year CPT codes 99393-99397, G0439, |
NOTE: Pelvic Examination add-on code 99459 should process per preventive services benefits when submitted in conjunction with the Well Woman Preventive Office Visits. |
PERINATAL DEPRESSION PREVENTIVE INTERVENTIONS
|
99401-99404 with a routine prenatal diagnosis code, high risk prenatal diagnosis code OR Z39.2 | |
PRECONCEPTION
|
99383-99387, G0438, or S0610 with Z31.69 or Z31.7 |
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PRENATAL CARE
|
99202-99215 with routine prenatal diagnosis, limited to 3 visits each calendar year 99202-99215 with high risk prenatal diagnosis 59425 regardless of diagnosis, limited to 2 visits each calendar year 59426 regardless of diagnosis, limited to 1 visit 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 routine and high-risk prenatal diagnosis codes. |
SCREENING FOR DIABETES AFTER PREGNANCYEffective 1/1/24
|
82947, 83036, 82951, or 82952 with Z86.32 | |
SCREENING FOR DIABETES DURING PREGNANCY
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82947, 83036, 82951, or 82952 with a routine prenatal or high risk prenatal diagnosis
|
See end of document for a list of routine and high-risk prenatal diagnosis codes. |
HIV COUNSELING
|
99401 or 99402 with diagnosis Z71.7 |
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CONTRACEPTIVE METHODS AND COUNSELING
|
99401 with diagnosis codes Z30.011- Z30.09, Z30.40-Z30.42, Z30.431, Z30.49, Z30.9, Z30.44, Z30.45, or Z30.46 | |
STERILIZATION
|
58600, 58661, 58605, 58611, 58615, 58670, 58671, 58700, 00851 with diagnosis code Z30.2 | Note: Effective 12/31/18, Essure (58565/ A4264) no longer available in the US. |
CONTRACEPTIVE METHODS- MEDICAL
|
A4261, A4266, 11976, 11981, 11982, 11983, 57170, 58300, 58301, J1050, J7296, J7297, J7298, J7300, J7301, J7303, J7304, J7306, J7307, S4981, S4989, with diagnosis codes Z30.013- Z30.019, Z30.09, Z30.40, Z30.42, Z30.430, Z30.431, Z30.432, Z30.433, Z30.44, Z30.45, Z30.46, Z30.49, Z30.9 9/30/2021 remove J7303 10/1/2021 add J7294, J7295 1/1/24 Add 96372 (for Depo-Provera administration) |
Note: (For dates of services prior to 1/1/24) Injection code 96372 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 |
CONTRACEPTIVE METHODS- MOBILE APPEffective 4/1/2024
|
A9293 with Z30.8, Z30.9, Z30.02, Z30.09 | Note: Coverage includes member reimbursement for the cost of FDA-approved, cleared, or granted mobile device applications for use as contraception consistent with the FDA-approved, cleared, or granted indication. Members must submit a Medical Expense Claim Form with an itemized receipt and prescription for reimbursement. |
CONTRACEPTIVE METHODS- PHARMACY
|
To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled by the pharmacy | Brand coverage may be available, contact Customer Service for additional information |
BREASTFEEDING – COUNSELING AND SUPPORT
Effective 1/1/2023
|
99402-99404 with modifier TH and diagnosis code Z39.1 | |
BREASTFEEDING – SUPPLIES(Pumps and Accessories)
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Pumps – E0602, E0603 with type service H for rental or G for purchase, E0604 (rental only) Accessories – A4281, A4282, A4283, A4284, A4285, A4286 1/1/2023 add code K1005 12/31/2023 Delete code K1005 1/1/2024 Add code A4287 |
E0603 – one pump allowed per pregnancy The requirement to cover the rental or purchase of breastfeeding equipment without cost sharing extends for the duration of breastfeeding, provided the individual remains continuously enrolled in the plan or coverage. |
SCREENING AND COUNSELING FOR INTERPERSONAL AND DOMESTIC VIOLENCE
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99401-99404 with diagnosis codes Z69.010-Z69.12, Z69.82
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SCREENING FOR INTIMATE PARTNER VIOLENCE AND ABUSE OF ELDERLY AND VULNERABLE ADULTS
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99401-99404 with diagnosis codes Z65.9, Z69.010-Z69.12, Z69.82, Z71.89 | |
PREVENTING OBESITY IN MIDLIFE WOMENEffective 1/1/2023
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99401, 99402, 99403, 99404 with diagnosis Z68.1, Z68.20, Z68.21, Z68.22, Z68.23, Z68.24, Z68.25, Z68.26, Z68.27, Z68.28, Z68.29 |
ROUTINE PRENATAL DIAGNOSIS CODES | O21.0, O22.00-O22.13, O22.40-O22.43, O22.8X1-O22.8X9, O42.10-O42.119, O47.00-O48.0, O92.011-O92.019, O92.111-O92.119, O92.20-O92.3, O92.5-O92.79, Z03.71-Z03.79, Z32.01, Z33.1, Z33.3, Z34.00-Z36.5, Z36.81-Z36.89, Z64.0 |
HIGH RISK PRENATAL DIAGNOSIS CODES |
O00-O07.4, O09.00-O10.019, O10.111-O10.119, O10.211-O10.219, O10.311-O10.319, O10.411-O10.419, O10.911-O10.919, O11.1-O15.03, O15.9-O20.9, O21.1- O21.9, O22.20-O22.33, O22.50-O22.53, O22.90-O24.019, O24.111-O24.119, O24.311-O24.319, O24.410-O24.419, O24.811-O24.819, O24.911-O24.919, O25.10- O25.13, O26.00-O26.43, O26.611-O26.619, O26.711-O26.719, O26.811-O26.93, O29.011-O30.93, O31.00X-O32.9XX (7th character 0,1,2,3,4,5, or 9), O33.0- O33.2, O33.3XX-O33.6XX (7th character 0,1,2,3,4,5, or 9), O33.7XX0-O34.93, O35.0XX-O41.93X (7th Character 0,1,2,3,4,5, or 9), O42.00-O42.019, O42.90- O42.919, O43.011-O46.93, O48.1-O60.03, O60.10X (7th character 0,1,2,3,4,5, or 9), O60.20X (7th character 0,1,2,3,4,5,or 9), O91.011-O91.019, O91.111-O91.119, O91.211-O91.219, O91.23, O98.011-O98.019, O98.111-O98.119, O98.211-O98.219, O98.311-O98.319, O98.411-O98.419, O98.511-O98.519, O98.611-O98.619, O98.711-O98.719, O98.811-O98.819, O98.911-O98.919, O99.011-O99.019, O99.111-O99.119, O99.210-O99.213, O99.280-O99.283, O99.310-O99.313, O99.320-O99.323, O99.330-O99.333, O99.340-O99.343, O99.350-O99.353, O99.411-O99.419, O99.511-O99.519, O99.611-O99.619, O99.711-O99.719, O99.810, O99.820, O99.830, O99.840-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 10/1/22 add O35.00X0, O35.00X1, O35.00X2, O35.00X3, O35.00X4, O35.00X5, O35.00X9, O35.01X0, O35.01X1, O35.01X2, O35.01X3, O35.01X4, O35.01X5, O35.01X9, O35.02X0, O35.02X1, O35.02X2, O35.02X3, O35.02X4, O35.02X5, O35.02X9, O35.03X0, O35.03X1, O35.03X2, O35.03X3, O35.03X4, O35.03X5, O35.03X9, O35.04X0, O35.04X1, O35.04X2, O35.04X3, O35.04X4, O35.04X5, O35.04X9, O35.05X0, O35.05X1, O35.05X2, O35.05X3, O35.05X4, O35.05X5, O35.05X9, O35.06X0, O35.06X1, O35.06X2, O35.06X3, O35.06X4, O35.06X5, O35.06X9, O35.07X0, O35.07X1, O35.07X2, O35.07X3, O35.07X4, O35.07X5, O35.07X9, O35.08X0, O35.08X1, O35.08X2, O35.08X3, O35.08X4, O35.08X5, O35.08X9, O35.09X0, O35.09X1, O35.09X2, O35.09X3, O35.09X4, O35.09X5, O35.09X9, O35.10X0, O35.10X1, O35.10X2, O35.10X3, O35.10X4, O35.10X5, O35.10X9, O35.11X0, O35.11X1, O35.11X2, O35.11X3, O35.11X4, O35.11X5, O35.11X9, O35.12X0, O35.12X1, O35.12X2, O35.12X3, O35.12X4, O35.12X5, O35.12X9, O35.13X0, O35.13X1, O35.13X2, O35.13X3, O35.13X4, O35.13X5, O35.13X9, O35.14X0, O35.14X1, O35.14X2, O35.14X3, O35.14X4, O35.14X5, O35.14X9, O35.15X0, O35.15X1, O35.15X2, O35.15X3, O35.15X4, O35.15X5, O35.15X9, O35.19X0, O35.19X1, O35.19X2, O35.19X3, O35.19X4, O35.19X5, O35.19X9, O35. AXX0, O35.AXX1, O35.AXX2, O35.AXX3, O35.AXX4, O35.AXX5, O35.AXX9, O35.BXX0, O35.BXX1, O35.BXX2, O35.BXX3, O35.BXX4, O35.BXX5, O35.BXX9, O35.CXX0, O35.CXX1, O35.CXX2, O35.CXX3, O35.CXX4, O35.CXX5, O35.CXX9, O35.DXX0, O35.DXX1, O35.DXX2, O35.DXX3, O35.DXX4, O35.DXX5, O35.DXX9, O35.EXX0, O35.EXX1, O35.EXX2, O35. EXX3, O35.EXX4, O35.EXX5, O35.EXX9, O35.FXX0, O35.FXX1, O35.FXX2, O35.FXX3, O35.FXX4, O35.FXX5, O35.FXX9, O35.GXX0, O35.GXX1, O35.GXX2, O35.GXX3, O35.GXX4, O35.GXX5, O35.GXX9, O35.HXX0, O35.HXX1, O35.HXX2, O35.HXX3, O35.HXX4, O35.HXX5, O35.HXX9 10/1/22 remove O350XX0, O350XX1, O350XX2, O350XX3, O350XX4, O350XX5, O350XX9, O351XX0, O351XX1, O351XX2, O351XX3, O351XX4, O351XX5, O351XX9 10/1/23 Add O26.641, O26.642, O26.643, O26.649 |
The Patient Protection and Affordable Care Act (ACA) defines preventive care services as follows:
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Items or services recommended with an A or B rating by the U.S. Preventive Services Task Force.
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Immunization recommended by the Advisory Committee on Immunization Practices (ACIP) of the Center for Disease Control (CDC). (children , adolescent, and adult)
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Preventive care and screening for infants, children, and adolescents supported by the Health Resources and Services Administration (Bright Futures).
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Preventive care and screening for women supported by the Health Resources and Service Administration. (These guidelines have not been defined yet.)
All providers must use the codes provided in this document when filing claims for healthcare reform mandated preventive services for a Blue Plan member.
If the preventive services section of your plan's benefit booklet refers to any of the preventive services and immunizations in this document, they will be covered by your 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 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 12/23 LR