Notification



Notification Issue Date:



Policy Attachment


Attachment to Policy # 00.06.02ab


Attachment:B

Policy #:00.06.02ab

Description:Female Preventive Care Services

Title:Preventive Care Services (Independence)


Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.



The intent of this attachment is to communicate services that may be considered female preventive care services for individuals or groups for whom these services apply.

The preventive services are organized as follows:

FEMALE PREVENTIVE CARE SERVICES
  • Visits
    • Prenatal Visits
    • Well-woman visits
  • Screenings
    • Sexually Transmitted Infections Screenings
      • Chlamydia Screening
      • Gonorrhea Screening
      • Human Immunodeficiency Virus (HIV) Screening
      • Syphilis Screening
    • Cancer Screenings
      • BRCA-related Cancer Risk Assessment, Genetic Counseling, and BRCA Mutation Testing
      • Breast Cancer Screening (Mammography)
      • Cervical Cancer Screening
    • Pregnancy-related Screenings
      • Bacteriuria screening
      • Counseling Interventions to Prevent Perinatal Depression
      • Depression Screening
      • Diabetes Mellitus Screening after Pregnancy
      • Gestational Diabetes Mellitus Screening
      • Iron-deficiency Anemia Screening
      • RhD Incompatibility Screening
    • Other Preventive Screenings
      • Hepatitis B Virus Screening
      • Human Papilloma Virus (HPV) Screening
      • Osteoporosis (Bone Mineral Density) Screening
  • Therapy and Counseling
    • Services Included as Part of the Comprehensive Preventive Exam or Well-Woman Visit
      • Primary Care Interventions to Promote and Support Breastfeeding
      • Discussion of Chemoprevention for Breast Cancer
      • Intimate Partner Violence Screening
      • Urinary Incontinence Screening
    • Tobacco Use Counseling
  • Medication
    • Low Dose Aspirin for Preeclampsia
    • Breast Cancer Chemoprevention
    • Folic Acid
  • Miscellaneous
    • Reproductive Education and Counseling, Contraception, and Sterilization
      • Associated Services for Contraceptive Surgery
    • Breastfeeding Support/Counseling and Supplies
    • Prolonged Preventive Services

Gender-specific preventive services as identified in this policy are covered for transgender individuals as determined by the individual's healthcare provider as medically appropriate.

VISITS

PRENATAL CARE VISIT

Once pregnancy has been established during the initial visit, routine prenatal care visits are considered a preventive service.

Preeclampsia screening is considered part of prenatal care visits, and is not eligible for separate reimbursement.

CPT Procedure Code Number(s) and Narrative(s)
Interrupted Prenatal Visits (4 or more)

59425, 59426

Interrupted Prenatal Visits (for visit 1-3).

99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215
ICD-10 Diagnosis Code Number(s) and Narrative(s) FOR PRENATAL CARE VISITS, CPT CODES 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, AND 99215 WILL ONLY BE COVERED AS A PREVENTIVE SERVICE FOR THE FOLLOWING DIAGNOSIS CODES:

O09.00 Supervision of pregnancy with history of infertility, unspecified trimester

O09.01 Supervision of pregnancy with history of infertility, first trimester

O09.02 Supervision of pregnancy with history of infertility, second trimester

O09.03 Supervision of pregnancy with history of infertility, third trimester

O09.10 Supervision of pregnancy with history of ectopic pregnancy, unspecified trimester

O09.11 Supervision of pregnancy with history of ectopic pregnancy, first trimester

O09.12 Supervision of pregnancy with history of ectopic pregnancy, second trimester

O09.13 Supervision of pregnancy with history of ectopic pregnancy, third trimester

O09.211 Supervision of pregnancy with history of pre-term labor, first trimester

O09.212 Supervision of pregnancy with history of pre-term labor, second trimester

O09.213 Supervision of pregnancy with history of pre-term labor, third trimester

O09.219 Supervision of pregnancy with history of pre-term labor, unspecified trimester

O09.291 Supervision of pregnancy with other poor reproductive or obstetric history, first trimester

O09.292 Supervision of pregnancy with other poor reproductive or obstetric history, second trimester

O09.293 Supervision of pregnancy with other poor reproductive or obstetric history, third trimester

O09.299 Supervision of pregnancy with other poor reproductive or obstetric history, unspecified trimester

O09.30 Supervision of pregnancy with insufficient antenatal care, unspecified trimester

O09.31 Supervision of pregnancy with insufficient antenatal care, first trimester

O09.32 Supervision of pregnancy with insufficient antenatal care, second trimester

O09.33 Supervision of pregnancy with insufficient antenatal care, third trimester

O09.40 Supervision of pregnancy with grand multiparity, unspecified trimester

O09.41 Supervision of pregnancy with grand multiparity, first trimester

O09.42 Supervision of pregnancy with grand multiparity, second trimester

O09.43 Supervision of pregnancy with grand multiparity, third trimester

O09.511 Supervision of elderly primigravida, first trimester

O09.512 Supervision of elderly primigravida, second trimester

O09.513 Supervision of elderly primigravida, third trimester

O09.519 Supervision of elderly primigravida, unspecified trimester

O09.52 Supervision of elderly multigravida

O09.521 Supervision of elderly multigravida, first trimester

O09.522 Supervision of elderly multigravida, second trimester

O09.523 Supervision of elderly multigravida, third trimester

O09.529 Supervision of elderly multigravida, unspecified trimester

O09.611 Supervision of young primigravida, first trimester

O09.612 Supervision of young primigravida, second trimester

O09.613 Supervision of young primigravida, third trimester

O09.619 Supervision of young primigravida, unspecified trimester

O09.621 Supervision of young multigravida, first trimester

O09.622 Supervision of young multigravida, second trimester

O09.623 Supervision of young multigravida, third trimester

O09.629 Supervision of young multigravida, unspecified trimester

O09.70 Supervision of high risk pregnancy due to social problems, unspecified trimester

O09.71 Supervision of high risk pregnancy due to social problems, first trimester

O09.72 Supervision of high risk pregnancy due to social problems, second trimester

O09.73 Supervision of high risk pregnancy due to social problems, third trimester

O09.81 Supervision of pregnancy resulting from assisted reproductive technology

O09.811 Supervision of pregnancy resulting from assisted reproductive technology, first trimester

O09.812 Supervision of pregnancy resulting from assisted reproductive technology, second trimester

O09.813 Supervision of pregnancy resulting from assisted reproductive technology, third trimester

O09.819 Supervision of pregnancy resulting from assisted reproductive technology, unspecified trimester

O09.821 Supervision of pregnancy with history of in utero procedure during previous pregnancy, first trimester

O09.822 Supervision of pregnancy with history of in utero procedure during previous pregnancy, second trimester

O09.823 Supervision of pregnancy with history of in utero procedure during previous pregnancy, third trimester

O09.829 Supervision of pregnancy with history of in utero procedure during previous pregnancy, unspecified trimester

O09.891 Supervision of other high risk pregnancies, first trimester

O09.892 Supervision of other high risk pregnancies, second trimester

O09.893 Supervision of other high risk pregnancies, third trimester

O09.899 Supervision of other high risk pregnancies, unspecified trimester

O09.90 Supervision of high risk pregnancy, unspecified, unspecified trimester

O09.91 Supervision of high risk pregnancy, unspecified, first trimester

O09.92 Supervision of high risk pregnancy, unspecified, second trimester

O09.93 Supervision of high risk pregnancy, unspecified, third trimester

O09.A0 Supervision of pregnancy with history of molar pregnancy, unspecified trimester

O09.A1 Supervision of pregnancy with history of molar pregnancy, first trimester

O09.A2 Supervision of pregnancy with history of molar pregnancy, second trimester

O09.A3 Supervision of pregnancy with history of molar pregnancy, third trimester

Z34.00 Encounter for supervision of normal first pregnancy, unspecified trimester

Z34.01 Encounter for supervision of normal first pregnancy, first trimester

Z34.02 Encounter for supervision of normal first pregnancy, second trimester

Z34.03 Encounter for supervision of normal first pregnancy, third trimester

Z34.80 Encounter for supervision of other normal pregnancy, unspecified trimester

Z34.81 Encounter for supervision of other normal pregnancy, first trimester

Z34.82 Encounter for supervision of other normal pregnancy, second trimester

Z34.83 Encounter for supervision of other normal pregnancy, third trimester

Z34.90 Encounter for supervision of normal pregnancy, unspecified, unspecified trimester

Z34.91 Encounter for supervision of normal pregnancy, unspecified, first trimester

Z34.92 Encounter for supervision of normal pregnancy, unspecified, second trimester

Z34.93 Encounter for supervision of normal pregnancy, unspecified, third trimester

HCPCS Level II Code Number(s) and Narrative(s) N/A

WELL-WOMAN VISITS
Well-woman visits are covered as a preventive service for all females to ensure that the recommended preventive services, including preconception and many services necessary for prenatal and interconception care are obtained. The primary purpose of the visit should be for delivery and coordination of recommended preventive services as determined by age and risk factors.

CPT Procedure Code Number(s) and Narrative(s)
INITIAL WELL-WOMAN VISIT

99383, 99384, 99385, 99386, 99387

SUBSEQUENT WELL-WOMAN VISIT

99393, 99394, 99395, 99396, 99397
ICD-10 Diagnosis Code Number(s) and Narrative(s) FOR WELL-WOMAN VISITS, CPT CODES 99383, 99384, 99385, 99386, 99387, 99393, 99394, 99395, 99396, 99397 WILL ONLY BE COVERED AS A PREVENTIVE SERVICE FOR THE FOLLOWING DIAGNOSIS CODES:

Z01.411 Encounter for gynecological examination (general) (routine) with abnormal findings

Z01.419 Encounter for gynecological examination (general) (routine) without abnormal findings

Z12.4 Encounter for screening for malignant neoplasm of cervix

Z12.72 Encounter for screening for malignant neoplasm of vagina

Z12.79 Encounter for screening for malignant neoplasm of other genitourinary organs
HCPCS Level II Code Number(s) and Narrative(s) S0610 Annual gynecological examination, new patient

S0612 Annual gynecological examination, established patient

S0613 Annual gynecological examination; clinical breast examination without pelvic evaluation

SCREENINGS

SEXUALLY TRANSMITTED INFECTIONS SCREENINGS
Chlamydia Screening

Chlamydia screening is covered as a preventive service for sexually active females, including pregnant females, age 24 years and younger and in older females who are at increased risk for infection whose sexual history reveals new or persistent risk factors since the last negative test result.

Risk factors for increased risk are:
  • Individual who has a new sex partner
  • Individual with more than one sex partner
  • Individual who has a sex partner with concurrent partners
  • Individual who has a sex partner who has a sexually transmitted infection
  • Inconsistent condom use for individuals who are not in a mutually monogamous relationship
  • History of or current diagnosis for sexually transmitted infection
  • Individuals who exchange sex for money or drug
CPT Procedure Code Number(s) and Narrative(s)
86631, 86632, 87110, 87270, 87320, 87490, 87491, 87810

WHEN THE FOLLOWING CODE IS REPORTED IN CONJUNCTION WITH CHLAMYDIA SCREENING, IT IS COVERED AS A PREVENTIVE SERVICE:

99000
ICD-10 Diagnosis Code Number(s) and Narrative(s) FOR CHLAMYDIA SCREENING, CPT CODES 86631, 86632, 87110, 87270, 87320, 87490, 87491, 87810 WILL ONLY BE COVERED AS A PREVENTIVE SERVICE FOR ANY APPROPRIATE PREGNANCY DIAGNOSIS CODE OR INCREASED RISK DIAGNOSIS CODE:

A50.01 Early congenital syphilitic oculopathy

A50.02 Early congenital syphilitic osteochondropathy

A50.03 Early congenital syphilitic pharyngitis

A50.04 Early congenital syphilitic pneumonia

A50.05 Early congenital syphilitic rhinitis

A50.06 Early cutaneous congenital syphilis

A50.07 Early mucocutaneous congenital syphilis

A50.08 Early visceral congenital syphilis

A50.09 Other early congenital syphilis, symptomatic

A50.1 Early congenital syphilis, latent

A50.2 Early congenital syphilis, unspecified

A50.30 Late congenital syphilitic oculopathy, unspecified

A50.31 Late congenital syphilitic interstitial keratitis

A50.32 Late congenital syphilitic chorioretinitis

A50.39 Other late congenital syphilitic oculopathy

A50.40 Late congenital neurosyphilis, unspecified

A50.41 Late congenital syphilitic meningitis

A50.42 Late congenital syphilitic encephalitis

A50.43 Late congenital syphilitic polyneuropathy

A50.44 Late congenital syphilitic optic nerve atrophy

A50.45 Juvenile general paresis

A50.49 Other late congenital neurosyphilis

A50.51 Clutton's joints

A50.52 Hutchinson's teeth

A50.53 Hutchinson's triad

A50.54 Late congenital cardiovascular syphilis

A50.55 Late congenital syphilitic arthropathy

A50.56 Late congenital syphilitic osteochondropathy

A50.57 Syphilitic saddle nose

A50.59 Other late congenital syphilis, symptomatic

A50.6 Late congenital syphilis, latent

A50.7 Late congenital syphilis, unspecified

A50.9 Congenital syphilis, unspecified

A51.1 Primary anal syphilis

A51.2 Primary syphilis of other sites

A51.31 Condyloma latum

A51.32 Syphilitic alopecia

A51.39 Other secondary syphilis of skin

A51.41 Secondary syphilitic meningitis

A51.42 Secondary syphilitic female pelvic disease

A51.43 Secondary syphilitic oculopathy

A51.44 Secondary syphilitic nephritis

A51.45 Secondary syphilitic hepatitis

A51.46 Secondary syphilitic osteopathy

A51.49 Other secondary syphilitic conditions

A51.5 Early syphilis, latent

A51.9 Early syphilis, unspecified

A52.00 Cardiovascular syphilis, unspecified

A52.01 Syphilitic aneurysm of aorta

A52.02 Syphilitic aortitis

A52.03 Syphilitic endocarditis

A52.04 Syphilitic cerebral arteritis

A52.05 Other cerebrovascular syphilis

A52.06 Other syphilitic heart involvement

A52.09 Other cardiovascular syphilis

A52.10 Symptomatic neurosyphilis, unspecified

A52.11 Tabes dorsalis

A52.12 Other cerebrospinal syphilis

A52.13 Late syphilitic meningitis

A52.14 Late syphilitic encephalitis

A52.15 Late syphilitic neuropathy

A52.16 Charcot's arthropathy (tabetic)

A52.17 General paresis

A52.19 Other symptomatic neurosyphilis

A52.2 Asymptomatic neurosyphilis

A52.3 Neurosyphilis, unspecified

A52.71 Late syphilitic oculopathy

A52.72 Syphilis of lung and bronchus

A52.73 Symptomatic late syphilis of other respiratory organs

A52.74 Syphilis of liver and other viscera

A52.75 Syphilis of kidney and ureter

A52.76 Other genitourinary symptomatic late syphilis

A52.77 Syphilis of bone and joint

A52.78 Syphilis of other musculoskeletal tissue

A52.79 Other symptomatic late syphilis

A52.8 Late syphilis, latent

A52.9 Late syphilis, unspecified

A53.0 Latent syphilis, unspecified as early or late

A53.9 Syphilis, unspecified

A54.00 Gonococcal infection of lower genitourinary tract, unspecified

A54.01 Gonococcal cystitis and urethritis, unspecified

A54.02 Gonococcal vulvovaginitis, unspecified

A54.03 Gonococcal cervicitis, unspecified

A54.09 Other gonococcal infection of lower genitourinary tract

A54.1 Gonococcal infection of lower genitourinary tract with periurethral and accessory gland abscess

A54.21 Gonococcal infection of kidney and ureter

A54.22 Gonococcal prostatitis

A54.23 Gonococcal infection of other male genital organs

A54.24 Gonococcal female pelvic inflammatory disease

A54.29 Other gonococcal genitourinary infections

A54.30 Gonococcal infection of eye, unspecified

A54.31 Gonococcal conjunctivitis

A54.32 Gonococcal iridocyclitis

A54.33 Gonococcal keratitis

A54.39 Other gonococcal eye infection

A54.40 Gonococcal infection of musculoskeletal system, unspecified

A54.41 Gonococcal spondylopathy

A54.42 Gonococcal arthritis

A54.43 Gonococcal osteomyelitis

A54.49 Gonococcal infection of other musculoskeletal tissue

A54.5 Gonococcal pharyngitis

A54.6 Gonococcal infection of anus and rectum

A55 Chlamydial lymphogranuloma (venereum)

A56.00 Chlamydial infection of lower genitourinary tract, unspecified

A56.01 Chlamydial cystitis and urethritis

A56.02 Chlamydial vulvovaginitis

A56.09 Other chlamydial infection of lower genitourinary tract

A56.11 Chlamydial female pelvic inflammatory disease

A56.19 Other chlamydial genitourinary infection

A56.2 Chlamydial infection of genitourinary tract, unspecified

A56.3 Chlamydial infection of anus and rectum

A56.4 Chlamydial infection of pharynx

A56.8 Sexually transmitted chlamydial infection of other sites

A59.00 Urogenital trichomoniasis, unspecified

A59.01 Trichomonal vulvovaginitis

A59.02 Trichomonal prostatitis

A59.03 Trichomonal cystitis and urethritis

A59.09 Other urogenital trichomoniasis

A59.8 Trichomoniasis of other sites

A59.9 Trichomoniasis, unspecified

A60.00 Herpesviral infection of urogenital system, unspecified

A60.01 Herpesviral infection of penis

A60.02 Herpesviral infection of other male genital organs

A60.03 Herpesviral cervicitis

A60.04 Herpesviral vulvovaginitis

A60.09 Herpesviral infection of other urogenital tract

A60.1 Herpesviral infection of perianal skin and rectum

A60.9 Anogenital herpesviral infection, unspecified

A63.0 Anogenital (venereal) warts

A63.8 Other specified predominantly sexually transmitted diseases

A65 Nonvenereal syphilis

A70 Chlamydia psittaci infections

A74.0 Chlamydial conjunctivitis

A74.81 Chlamydial peritonitis

A74.89 Other chlamydial diseases

A74.9 Chlamydial infection, unspecified

B00.0 Eczema herpeticum

B00.1 Herpesviral vesicular dermatitis

B00.2 Herpesviral gingivostomatitis and pharyngotonsillitis

B00.3 Herpesviral meningitis

B00.4 Herpesviral encephalitis

B00.50 Herpesviral ocular disease, unspecified

B00.51 Herpesviral iridocyclitis

B00.52 Herpesviral keratitis

B00.53 Herpesviral conjunctivitis

B00.59 Other herpesviral disease of eye

B20 Human immunodeficiency virus [HIV] disease

B37.3 Candidiasis of vulva and vagina

B97.7 Papillomavirus as the cause of diseases classified elsewhere

F52.8 Other sexual dysfunction not due to a substance or known physiological condition: excessive sexual drive, nymphomania, satyriasis

N34.0 Urethral abscess

N34.1 Nonspecific urethritis

N34.2 Other urethritis

N34.3 Urethral syndrome, unspecified

N72 Inflammatory disease of cervix uteri

N73.0 Acute parametritis and pelvic cellulitis

N73.1 Chronic parametritis and pelvic cellulitis

N73.2 Unspecified parametritis and pelvic cellulitis

N73.3 Female acute pelvic peritonitis

N73.4 Female chronic pelvic peritonitis

N73.5 Female pelvic peritonitis, unspecified

N73.6 Female pelvic peritoneal adhesions (postinfective)

N73.8 Other specified female pelvic inflammatory diseases

N73.9 Female pelvic inflammatory disease, unspecified

P35.2 Congenital herpesviral [herpes simplex] infection

R85.81 Anal high risk human papillomavirus (HPV) DNA test positive

R85.82 Anal low risk human papillomavirus (HPV) DNA test positive

R87.810 Cervical high risk human papillomavirus (HPV) DNA test positive

R87.811 Vaginal high risk human papillomavirus (HPV) DNA test positive

R87.820 Cervical low risk human papillomavirus (HPV) DNA test positive

R87.821 Vaginal low risk human papillomavirus (HPV) DNA test positive

Z00.00 Encounter for general adult medical examination without abnormal findings

Z00.01 Encounter for general adult medical examination with abnormal findings

Z00.121 Encounter for routine child health examination with abnormal findings

Z00.129 Encounter for routine child health examination without abnormal findings

Z01.411 Encounter for gynecological examination (general) (routine) with abnormal findings

Z01.419 Encounter for gynecological examination (general) (routine) without abnormal findings

Z11.2 Encounter for screening for other bacterial diseases

Z11.3 Encounter for screening for infections with a predominantly sexual mode of transmission

Z20.2 Contact with and (suspected) exposure to infections with a predominantly sexual mode of transmission

Z21 Asymptomatic human immunodeficiency virus [HIV] infection status

Z72.51 High risk heterosexual behavior

Z72.52 High risk homosexual behavior

Z72.53 High risk bisexual behavior

Z86.19 Personal history of other infectious and parasitic diseases

Z91.42 Personal history of forced labor or sexual exploitation

HCPCS Level II Code Number(s) and Narrative(s) N/A

Gonorrhea Screening
Gonorrhea screening is covered as a preventive service for sexually active females, including pregnant females, age 24 years and younger and in older females who are at increased risk for infection whose sexual history reveals new or persistent risk factors since the last negative test result.

Risk factors for increased risk are:
  • Individual who has a new sex partner
  • Individual with more than one sex partner
  • Individual who has a sex partner with concurrent partners
  • Individual who has a sex partner who has a sexually transmitted infection
  • Inconsistent condom use for individuals who are not in a mutually monogamous relationship
  • History of or current diagnosis for sexually transmitted infection
  • Individuals who exchange sex for money or drug
CPT Procedure Code Number(s) and Narrative(s)
87590, 87591, 87850

WHEN THE FOLLOWING CODE IS REPORTED IN CONJUNCTION WITH GONORRHEA SCREENING, IT IS COVERED AS A PREVENTIVE SERVICE:

99000
ICD-10 Diagnosis Code Number(s) and Narrative(s) FOR GONORRHEA SCREENING, CPT CODES 87590, 87591, 87850 WILL ONLY BE COVERED AS A PREVENTIVE SERVICE FOR ANY APPROPRIATE PREGNANCY DIAGNOSIS CODE OR INCREASED RISK DIAGNOSIS CODE:

A50.01 Early congenital syphilitic oculopathy

A50.02 Early congenital syphilitic osteochondropathy

A50.03 Early congenital syphilitic pharyngitis

A50.04 Early congenital syphilitic pneumonia

A50.05 Early congenital syphilitic rhinitis

A50.06 Early cutaneous congenital syphilis

A50.07 Early mucocutaneous congenital syphilis

A50.08 Early visceral congenital syphilis

A50.09 Other early congenital syphilis, symptomatic

A50.1 Early congenital syphilis, latent

A50.2 Early congenital syphilis, unspecified

A50.30 Late congenital syphilitic oculopathy, unspecified

A50.31 Late congenital syphilitic interstitial keratitis

A50.32 Late congenital syphilitic chorioretinitis

A50.39 Other late congenital syphilitic oculopathy

A50.40 Late congenital neurosyphilis, unspecified

A50.41 Late congenital syphilitic meningitis

A50.42 Late congenital syphilitic encephalitis

A50.43 Late congenital syphilitic polyneuropathy

A50.44 Late congenital syphilitic optic nerve atrophy

A50.45 Juvenile general paresis

A50.49 Other late congenital neurosyphilis

A50.51 Clutton's joints

A50.52 Hutchinson's teeth

A50.53 Hutchinson's triad

A50.54 Late congenital cardiovascular syphilis

A50.55 Late congenital syphilitic arthropathy

A50.56 Late congenital syphilitic osteochondropathy

A50.57 Syphilitic saddle nose

A50.59 Other late congenital syphilis, symptomatic

A50.6 Late congenital syphilis, latent

A50.7 Late congenital syphilis, unspecified

A50.9 Congenital syphilis, unspecified

A51.1 Primary anal syphilis

A51.2 Primary syphilis of other sites

A51.31 Condyloma latum

A51.32 Syphilitic alopecia

A51.39 Other secondary syphilis of skin

A51.41 Secondary syphilitic meningitis

A51.42 Secondary syphilitic female pelvic disease

A51.43 Secondary syphilitic oculopathy

A51.44 Secondary syphilitic nephritis

A51.45 Secondary syphilitic hepatitis

A51.46 Secondary syphilitic osteopathy

A51.49 Other secondary syphilitic conditions

A51.5 Early syphilis, latent

A51.9 Early syphilis, unspecified

A52.00 Cardiovascular syphilis, unspecified

A52.01 Syphilitic aneurysm of aorta

A52.02 Syphilitic aortitis

A52.03 Syphilitic endocarditis

A52.04 Syphilitic cerebral arteritis

A52.05 Other cerebrovascular syphilis

A52.06 Other syphilitic heart involvement

A52.09 Other cardiovascular syphilis

A52.10 Symptomatic neurosyphilis, unspecified

A52.11 Tabes dorsalis

A52.12 Other cerebrospinal syphilis

A52.13 Late syphilitic meningitis

A52.14 Late syphilitic encephalitis

A52.15 Late syphilitic neuropathy

A52.16 Charcot's arthropathy (tabetic)

A52.17 General paresis

A52.19 Other symptomatic neurosyphilis

A52.2 Asymptomatic neurosyphilis

A52.3 Neurosyphilis, unspecified

A52.71 Late syphilitic oculopathy

A52.72 Syphilis of lung and bronchus

A52.73 Symptomatic late syphilis of other respiratory organs

A52.74 Syphilis of liver and other viscera

A52.75 Syphilis of kidney and ureter

A52.76 Other genitourinary symptomatic late syphilis

A52.76 Other genitourinary symptomatic late syphilis

A52.76 Other genitourinary symptomatic late syphilis

A52.77 Syphilis of bone and joint

A52.78 Syphilis of other musculoskeletal tissue

A52.79 Other symptomatic late syphilis

A52.8 Late syphilis, latent

A52.9 Late syphilis, unspecified

A53.0 Latent syphilis, unspecified as early or late

A53.9 Syphilis, unspecified

A54.00 Gonococcal infection of lower genitourinary tract, unspecified

A54.01 Gonococcal cystitis and urethritis, unspecified

A54.02 Gonococcal vulvovaginitis, unspecified

A54.03 Gonococcal cervicitis, unspecified

A54.09 Other gonococcal infection of lower genitourinary tract

A54.1 Gonococcal infection of lower genitourinary tract with periurethral and accessory gland abscess

A54.21 Gonococcal infection of kidney and ureter

A54.22 Gonococcal prostatitis

A54.23 Gonococcal infection of other male genital organs

A54.24 Gonococcal female pelvic inflammatory disease

A54.29 Other gonococcal genitourinary infections

A54.30 Gonococcal infection of eye, unspecified

A54.31 Gonococcal conjunctivitis

A54.32 Gonococcal iridocyclitis

A54.33 Gonococcal keratitis

A54.39 Other gonococcal eye infection

A54.40 Gonococcal infection of musculoskeletal system, unspecified

A54.41 Gonococcal spondylopathy

A54.42 Gonococcal arthritis

A54.43 Gonococcal osteomyelitis

A54.49 Gonococcal infection of other musculoskeletal tissue

A54.5 Gonococcal pharyngitis

A54.6 Gonococcal infection of anus and rectum

A55 Chlamydial lymphogranuloma (venereum)

A56.00 Chlamydial infection of lower genitourinary tract, unspecified

A56.01 Chlamydial cystitis and urethritis

A56.02 Chlamydial vulvovaginitis

A56.09 Other chlamydial infection of lower genitourinary tract

A56.11 Chlamydial female pelvic inflammatory disease

A56.19 Other chlamydial genitourinary infection

A56.2 Chlamydial infection of genitourinary tract, unspecified

A56.3 Chlamydial infection of anus and rectum

A56.4 Chlamydial infection of pharynx

A56.8 Sexually transmitted chlamydial infection of other sites

A59.00 Urogenital trichomoniasis, unspecified

A59.01 Trichomonal vulvovaginitis

A59.02 Trichomonal prostatitis

A59.03 Trichomonal cystitis and urethritis

A59.09 Other urogenital trichomoniasis

A59.8 Trichomoniasis of other sites

A59.9 Trichomoniasis, unspecified

A60.00 Herpesviral infection of urogenital system, unspecified

A60.01 Herpesviral infection of penis

A60.02 Herpesviral infection of other male genital organs

A60.03 Herpesviral cervicitis

A60.04 Herpesviral vulvovaginitis

A60.09 Herpesviral infection of other urogenital tract

A60.1 Herpesviral infection of perianal skin and rectum

A60.9 Anogenital herpesviral infection, unspecified

A63.0 Anogenital (venereal) warts

A63.8 Other specified predominantly sexually transmitted diseases

A65 Nonvenereal syphilis

A70 Chlamydia psittaci infections

A74.0 Chlamydial conjunctivitis

A74.81 Chlamydial peritonitis

A74.89 Other chlamydial diseases

A74.9 Chlamydial infection, unspecified

B00.0 Eczema herpeticum

B00.1 Herpesviral vesicular dermatitis

B00.2 Herpesviral gingivostomatitis and pharyngotonsillitis

B00.3 Herpesviral meningitis

B00.4 Herpesviral encephalitis

B00.50 Herpesviral ocular disease, unspecified

B00.51 Herpesviral iridocyclitis

B00.52 Herpesviral keratitis

B00.53 Herpesviral conjunctivitis

B00.59 Other herpesviral disease of eye

B20 Human immunodeficiency virus [HIV] disease

B37.3 Candidiasis of vulva and vagina

B97.7 Papillomavirus as the cause of diseases classified elsewhere

F52.8 Other sexual dysfunction not due to a substance or known physiological condition: excessive sexual drive, nymphomania, satyriasis

N34.0 Urethral abscess

N34.1 Nonspecific urethritis

N34.2 Other urethritis

N34.3 Urethral syndrome, unspecified

N72 Inflammatory disease of cervix uteri

N73.0 Acute parametritis and pelvic cellulitis

N73.1 Chronic parametritis and pelvic cellulitis

N73.2 Unspecified parametritis and pelvic cellulitis

N73.3 Female acute pelvic peritonitis

N73.4 Female chronic pelvic peritonitis

N73.5 Female pelvic peritonitis, unspecified

N73.6 Female pelvic peritoneal adhesions (postinfective)

N73.8 Other specified female pelvic inflammatory diseases

N73.9 Female pelvic inflammatory disease, unspecified

P35.2 Congenital herpesviral [herpes simplex] infection

R85.81 Anal high risk human papillomavirus (HPV) DNA test positive

R85.82 Anal low risk human papillomavirus (HPV) DNA test positive

R87.810 Cervical high risk human papillomavirus (HPV) DNA test positive

R87.811 Vaginal high risk human papillomavirus (HPV) DNA test positive

R87.820 Cervical low risk human papillomavirus (HPV) DNA test positive

R87.821 Vaginal low risk human papillomavirus (HPV) DNA test positive

Z00.00 Encounter for general adult medical examination without abnormal findings

Z00.01 Encounter for general adult medical examination with abnormal findings

Z00.121 Encounter for routine child health examination with abnormal findings

Z00.129 Encounter for routine child health examination without abnormal findings

Z01.411 Encounter for gynecological examination (general) (routine) with abnormal findings

Z01.419 Encounter for gynecological examination (general) (routine) without abnormal findings

Z11.2 Encounter for screening for other bacterial diseases

Z11.3 Encounter for screening for infections with a predominantly sexual mode of transmission

Z20.2 Contact with and (suspected) exposure to infections with a predominantly sexual mode of transmission

Z21 Asymptomatic human immunodeficiency virus [HIV] infection status

Z72.5 High risk sexual behavior

Z72.51 High risk heterosexual behavior

Z72.52 High risk homosexual behavior

Z72.53 High risk bisexual behavior

Z86.19 Personal history of other infectious and parasitic diseases

Z91.42 Personal history of forced labor or sexual exploitation

HCPCS Level II Code Number(s) and Narrative(s) N/A

Human Immunodeficiency Virus (HIV) Screening
Human immunodeficiency virus (HIV) screening is covered as a preventive service for all pregnant females during each pregnancy, including those who present in labor who are untested and whose HIV status is unknown. HIV testing is covered as a preventive service at initiation of prenatal care and retesting based on risk factors during pregnancy.

CPT Procedure Code Number(s) and Narrative(s)
86689, 86701, 86702, 86703, 87389, 87390, 87391, 87806

WHEN THE FOLLOWING CODES ARE REPORTED IN CONJUNCTION WITH HIV SCREENING, THEY ARE COVERED AS A PREVENTIVE SERVICE:

36415, 36416, 99000
ICD-10 Diagnosis Code Number(s) and Narrative(s) FOR HIV SCREENING, CPT CODES 86689, 86701, 86702, 86703, 87389, 87390, 87391, 87806, AND HCPCS CODE S3645 WILL ONLY BE COVERED AS A PREVENTIVE SERVICE FOR THE FOLLOWING DIAGNOSIS CODES:

Z00.00 Encounter for general adult medical examination without abnormal findings

Z00.01 Encounter for general adult medical examination with abnormal findings

Z01.411 Encounter for gynecological examination (general) (routine) with abnormal findings

Z01.419 Encounter for gynecological examination (general) (routine) without abnormal findings

Z11.3 Encounter for screening for infections with a predominantly sexual mode of transmission

Z11.4 Encounter for screening for human immunodeficiency virus [HIV]
HCPCS Level II Code Number(s) and Narrative(s) G0432 Infectious agent antibody detection by enzyme immunoassay (EIA) technique, HIV-1 and/or HIV-2, screening

G0433 Infectious agent antibody detection by enzyme-linked immunosorbent assay (ELISA) technique, HIV-1 and/or HIV-2, screening

G0435 Infectious agent antigen detection by rapid antibody test of oral mucosa transudate, HIV-1 or HIV-2, screening

G0475 HIV antigen/antibody, combination assay, screening

S3645 HIV-1 antibody testing of oral mucosal transudate

Syphilis Screening
Syphilis screening is covered as a preventive service when any of the following criteria are met:
  • All pregnant females at first prenatal visit.
  • For high-risk pregnant females, repeat testing may be required in the third trimester and at delivery.
  • Individuals at increased risk for syphilis infection, including individuals who are HIV positive.
    Risk factors for increased risk include:
    • Males who have sex with males
    • Individuals who are HIV positive
    • Individuals with a history of incarceration
    • Individuals with a history of commercial sex work
    • Males younger than 29 years
    • Individuals having sex with multiple partners
    • Individuals having a sexual partner who has tested positive for syphilis
CPT Procedure Code Number(s) and Narrative(s)
80055, 80081, 86592, 86780

WHEN THE FOLLOWING CODES ARE REPORTED IN CONJUNCTION WITH SYPHILIS SCREENING, THEY ARE COVERED AS A PREVENTIVE SERVICE:

36415, 36416, 99000
ICD-10 Diagnosis Code Number(s) and Narrative(s) FOR SYPHILIS SCREENING, CPT CODES 86592, 86780 WILL ONLY BE COVERED AS A PREVENTIVE SERVICE FOR ANY APPROPRIATE PREGNANCY DIAGNOSIS CODE OR INCREASED RISK DIAGNOSIS CODE:

B20 Human immunodeficiency virus [HIV] disease

F52.8 Other sexual dysfunction not due to a substance or known physiological condition

Z00.00 Encounter for general adult medical examination without abnormal findings


Z00.01 Encounter for general adult medical examination with abnormal findings

Z00.121 Encounter for routine child health examination with abnormal findings

Z00.129 Encounter for routine child health examination without abnormal findings

Z01.411 Encounter for gynecological examination (general) (routine) with abnormal findings

Z01.419 Encounter for gynecological examination (general) (routine) without abnormal findings

Z11.2 Encounter for screening for other bacterial diseases


Z11.3 Encounter for screening for infections with a predominantly sexual mode of transmission

Z20.2 Contact with and (suspected) exposure to infections with a predominantly sexual mode of transmission

Z21 Asymptomatic human immunodeficiency virus

Z65.1 Imprisonment and other incarceration

Z72.51 High risk heterosexual behavior

Z72.52 High risk homosexual behavior

Z72.53 High risk bisexual behavior

Z77.21 Contact with and (suspected) exposure to potentially hazardous body fluids

Z91.42 Personal history of forced labor or sexual exploitation

HCPCS Level II Code Number(s) and Narrative(s) N/A

CANCER SCREENING
BRCA-related Cancer Risk Assessment, Genetic Counseling, and BRCA Mutation Testing

BRCA-related Cancer Risk Assessment
BRCA-related cancer risk assessment is covered as a preventive service as part of a well-woman visit for asymptomatic females with no known personal history of a BRCA-related cancer who have a family history of breast, ovarian, tubal, or peritoneal cancer.

Genetic Counseling
Genetic counseling is covered as a preventive service for any of the following:
  • Asymptomatic females with no known personal history of a BRCA-related cancer who have a family history of breast, ovarian, tubal, or peritoneal cancer, with a positive risk assessment
  • Asymptomatic females who have a personal history of breast, ovarian, tubal, or peritoneal cancer, and these cancers have not been tested for BRCA1 and BRCA2 mutations

BRCA Mutation Testing
Following genetic counseling, BRCA1 and BRCA2 testing is covered as a preventive service when medical necessity criteria are met.

For medical necessity criteria on BRCA testing, refer to the Evicore guidelines, 06.02.52 eviCore Lab Management Program (Independence). For members enrolled in Independence Administrators plans refer to medical policy 06.02.06, Genetic Testing for Inherited Breast Cancer 1 (BRCA1) and Breast Cancer 2 (BRCA2) Mutations.

CPT Procedure Code Number(s) and Narrative(s)
81162, 81163, 81164, 81165, 81166, 81167, 81212, 81215, 81216, 81217

THE FOLLOWING CODES SHOULD BE REPORTED BY A PHYSICIAN OR OTHER QUALIFIED HEALTHCARE PROFESSIONAL. A GENETIC COUNSELOR SHOULD NOT REPORT THESE CODES:

99401, 99402, 99403, 99404, 99411, 99412

THE FOLLOWING CODE IS APPROPRIATE WHEN REPORTED BY A GENETIC COUNSELOR. WHEN PERFORMED BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, THE PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL SHOULD USE THE APPROPRIATE EVALUATION AND MANAGEMENT EXAM CODES:

96040

WHEN THE FOLLOWING CODES ARE REPORTED IN CONJUNCTION WITH BRCA TESTING THAT IS CONSIDERED PREVENTIVE, THEY ARE CONSIDERED A PREVENTIVE SERVICE:

36415, 36416, 99000
ICD-10 Diagnosis Code Number(s) and Narrative(s) FOR GENETIC COUNSELING AND BRCA TESTING, CPT CODES 81211, 81212, 81213, 81214, 81215, 81216, 81217, AND 96040, AND HCPCS CODE S0265 WILL ONLY BE COVERED AS A PREVENTIVE SERVICE FOR THE FOLLOWING DIAGNOSIS CODES:

Z15.01 Genetic susceptibility to malignant neoplasm of breast

Z15.02 Genetic susceptibility to malignant neoplasm of ovary

Z80.3 Family history of malignant neoplasm of breast

Z80.41 Family history of malignant neoplasm of ovary

Z85.3 Personal history of malignant neoplasm of breast

Z85.43 Personal history of malignant neoplasm of ovary

Z85.44 Personal history of malignant neoplasm of other female genital organs
HCPCS Level II Code Number(s) and Narrative(s) THE FOLLOWING CODE IS APPROPRIATE WHEN REPORTED BY A GENETIC COUNSELOR. WHEN PERFORMED BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, THE PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL SHOULD USE THE APPROPRIATE EVALUATION AND MANAGEMENT EXAM CODES:

S0265 Genetic counseling, under physician supervision, each 15 minutes

Breast Cancer Screening (Mammography)
Screening mammography is covered as a preventive service for females age 40 years and older, with or without clinical breast examination.

* In accordance with Pennsylvania state mandates, screening mammography is covered as a preventive service for females under 40 years of age based on the provider's recommendation.

CPT Procedure Code Number(s) and Narrative(s)
77063, 77067
ICD-10 Diagnosis Code Number(s) and Narrative(s) N/A
HCPCS Level II Code Number(s) and Narrative(s) N/A

Cervical Cancer Screening
Cervical cancer screening is covered as a preventive service for asymptomatic females when all of the following criteria are met:
  • Ages 21 to 65 years
  • The female does not have any of the following conditions:
    • Diagnosed with a high-grade precancerous cervical lesion or cervical cancer
    • In utero esposure to diethylstilbestrol
    • Immunocompromised (e.g. HIV, receiving solid organ transplantation)
    • Previous history of a hysterectomy with removal of the cervix and previous diagnosis of a high-grade precancerous cervical lesion or cervical cancer

The USPSTF recommends the following preventive schedule:
  • Females 21 to 65 years with cytology (Pap Smear) every three years*
  • Females 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years*

*The frequency schedule may be different based on member's benefit contracts.
CPT Procedure Code Number(s) and Narrative(s) 88141, 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88155, 88164, 88165, 88166, 88167, 88174, 88175

WHEN THE FOLLOWING CODE IS REPORTED IN CONJUNCTION WITH CERVICAL CANCER SCREENING THAT IS CONSIDERED PREVENTIVE, IT IS CONSIDERED A PREVENTIVE SERVICE:

99000
ICD-10 Diagnosis Code Number(s) and Narrative(s) N/A
HCPCS Level II Code Number(s) and Narrative(s) G0101 Cervical or vaginal cancer screening; pelvic and clinical breast examination
G0123 Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, screening by cytotechnologist under physician supervision

G0124 Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, requiring interpretation by physician

G0141 Screening cytopathology smears, cervical or vaginal, performed by automated system, with manual rescreening, requiring interpretation by physician

G0143 Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and rescreening by cytotechnologist under physician supervision

G0144 Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system, under physician supervision

G0145 Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system and manual rescreening under physician supervision

G0147 Screening cytopathology smears, cervical or vaginal, performed by automated system under physician supervision

G0148 Screening cytopathology smears, cervical or vaginal, performed by automated system with manual rescreening

P3000 Screening Papanicolaou smear, cervical or vaginal, up to 3 smears, by technician under physician supervision

P3001 Screening Papanicolaou smear, cervical or vaginal, up to 3 smears, requiring interpretation by physician

Q0091 Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory

PREGNANCY-RELATED SCREENINGS

Bacteriuria Screening
Bacteriuria screening with urine culture is covered as a preventive service for asymptomatic pregnant females at 12 to 16 weeks gestation or at the first prenatal visit, if later.

CPT Procedure Code Number(s) and Narrative(s)
THE FOLLOWING CPT CODES ARE APPROPRIATE FOR REPORTING BACTERIURIA SCREENING FOR ANY APPROPRIATE PREGNANCY DIAGNOSIS CODE:

81007, 87081

WHEN THE FOLLOWING CODE IS REPORTED IN CONJUNCTION WITH BACTERIURIA SCREENING THAT IS CONSIDERED PREVENTIVE, IT IS CONSIDERED A PREVENTIVE SERVICE:

99000
ICD-10 Diagnosis Code Number(s) and Narrative(s) N/A
HCPCS Level II Code Number(s) and Narrative(s) N/A

Counseling Interventions to Prevent Perinatal Depression
Counseling interventions (i.e. cognitive behavioral therapy and interpersonal therapy) to prevent perinatal depression are covered as a preventive service when all of the criteria are met:
  • The individual is pregnant or is within one year of postpartum period.
  • No current diagnosis of depression
  • The individual has Increased risk factors of perinatal depression. Risk factors of perinatal depression screening are:
    • Past history of depression
    • Current depressive symptoms
    • History of Physical and sexual abuse
    • Unplanned or unwanted pregnancy
    • Stressful life events
    • Lack of social and financial support
    • Intimate partner violence
    • Pregestational or gestational diabetes
    • Complications during pregnancy
    • Adolescent parenthood
    • Low socioeconomic status
    • Lack of social support
Frequency

When the above criteria are met, counseling interventions for perinatal depression is covered as preventive up to 20 sessions over a 70 week period.
    CPT Procedure Code Number(s) and Narrative(s) 90832, 90833, 90834, 90836, 90837, 90838
    ICD-10 Diagnosis Code Number(s) and Narrative(s) FOR COUNSELING INTERVENTIONS FOR PERINATAL DEPRESSION, CPT CODES 90832, 90833, 90834, 90836, 90837, AND 90838 WILL BE COVERED AS A PREVENTIVE SERVICE WHEN REPORTED WITH ONE OF THE FOLLOWING DIAGNOSIS CODES AND WITHOUT A DEPRESSION DIAGNOSIS CODE:


    O24.319 Unspecified pre-existing diabetes mellitus in pregnancy, unspecified trimester

    O24.32 Unspecified pre-existing diabetes mellitus in childbirth

    O24.419 Gestational diabetes mellitus in pregnancy, unspecified control

    Z59.7 Insufficient social insurance and welfare support

    Z59.9 Problem related to housing and economic circumstances, unspecified

    Z60.4 Social exclusion and rejection

    Z60.5 Target of (perceived) adverse discrimination and persecution

    Z60.8 Other problems related to social environment

    Z62.810 Personal history of physical and sexual abuse in childhood

    Z62.813 Personal history of forced labor or sexual exploitation in childhood

    Z63.79 Other stressful life events affecting family and household

    Z64.0 Problems related to unwanted pregnancy

    Z69.11 Encounter for mental health services for victim of spousal or partner abuse

    Z86.51 Personal history of combat and operational stress reaction

    Z86.59 Personal history of other mental and behavioral disorders

    Z91.410 Personal history of adult physical and sexual abuse

    Z91.42 Personal history of forced labor or sexual exploitation

    Z91.5 Personal history of self-harm

    HCPCS Level II Code Number(s) and Narrative(s) N/A


Depression Screening
Depression screening is covered as a preventive service for pregnant and postpartum females when adequate measures are in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.

CPT Procedure Code Number(s) and Narrative(s) 96127
ICD-10 Diagnosis Code Number(s) and Narrative(s) FOR DEPRESSION SCREENING, CPT CODE 96127 WILL ONLY BE COVERED AS A PREVENTIVE SERVICE FOR THE FOLLOWING DIAGNOSIS CODES:

F53.0 Postpartum depression

F53.1 Puerperal psychosis

Z13.32 Encounter for screening for maternal depression

HCPCS Level II Code Number(s) and Narrative(s) G0444 Annual depression screening, 15 minutes

Diabetes Mellitus Screening after Pregnancy
Diabetes mellitus screening after pregnancy is covered as a preventive service for females with a history of gestational diabetes mellitus who are not currently pregnant and who have not previously been diagnosed with type 2 diabetes mellitus.

The initial diabetes mellitus screening is covered as preventive within the first year postpartum. Repeat diabetes mellitus screening is covered as preventive for women who were screened with hemoglobin A1c in the first six months postpartum regardless of results. If the initial postpartum screening is negative then repeat postpartum screening is covered as preventive every 3 years for 10 years.

CPT Procedure Code Number(s) and Narrative(s) 82947, 82950, 82951, 82952, 83036

WHEN THE FOLLOWING CODES ARE REPORTED IN CONJUNCTION WITH DIABETES MELLITUS SCREENING AFTER PREGNANCY, THEY ARE COVERED AS A PREVENTIVE SERVICE:

36415, 36416, 99000
ICD-10 Diagnosis Code Number(s) and Narrative(s) FOR DIABETES MELLITUS SCREENING AFTER PREGNANCY, CPT CODES 82947, 82950, 82951, 82952 AND 83036 WILL ONLY BE COVERED AS A PREVENTIVE SERVICE FOR THE FOLLOWING DIAGNOSIS CODES:

Z86.32 Personal history of gestational diabetes
HCPCS Level II Code Number(s) and Narrative(s) N/A


Gestational Diabetes Mellitus Screening
Gestational diabetes screening is covered as a preventive service when either of the following criteria is met:
  • Asymptomatic pregnant females after 24 weeks of gestation
  • First prenatal visit for pregnant females identified to be at high risk for diabetes
CPT Procedure Code Number(s) and Narrative(s)
THE FOLLOWING CPT CODES ARE APPROPRIATE FOR REPORTING GESTATIONAL DIABETES SCREENING FOR ANY APPROPRIATE PREGNANCY DIAGNOSIS CODE OR DIABETES SCREENING DIAGNOSIS CODE:

82947, 82950, 82951, 82952

WHEN THE FOLLOWING CODES ARE REPORTED IN CONJUNCTION WITH GESTATIONAL DIABETES MELLITUS SCREENING, THEY ARE COVERED AS A PREVENTIVE SERVICE:

36415, 36416, 99000
ICD-10 Diagnosis Code Number(s) and Narrative(s) N/A
HCPCS Level II Code Number(s) and Narrative(s) N/A

Iron-deficiency Anemia Screening
Iron deficiency anemia screening is covered as a preventive service on a routine basis for pregnant females.

CPT Procedure Code Number(s) and Narrative(s)
80055, 80081

WHEN THE FOLLOWING CODES ARE REPORTED IN CONJUNCTION WITH IRON DEFICIENCY ANEMIA SCREENING, THEY ARE COVERED AS A PREVENTIVE SERVICE

36415, 36416, 99000
ICD-9 Diagnosis Code Number(s) and Narrative(s) N/A
ICD-10 Diagnosis Code Number(s) and Narrative(s) N/A
HCPCS Level II Code Number(s) and Narrative(s) N/A

RhD Incompatibility Screening
RhD incompatibility screening is covered as a preventive service for all pregnant females and follow-up testing for women at higher risk.

CPT Procedure Code Number(s) and Narrative(s)
80055, 80081, 86870

WHEN THE FOLLOWING CODES ARE REPORTED IN CONJUNCTION WITH RHD INCOMPATIBILITY SCREENING, THEY ARE COVERED AS A PREVENTIVE SERVICE

36415, 36416, 99000
ICD-10 Diagnosis Code Number(s) and Narrative(s) FOR RHD INCOMPATIBILITY SCREENING, CPT CODE 86870 WILL ONLY BE COVERED AS A PREVENTIVE SERVICE FOR THE FOLLOWING DIAGNOSIS CODES:

O36.0110 Maternal care for anti-D [Rh] antibodies, first trimester, not applicable or unspecified

O36.0111 Maternal care for anti-D [Rh] antibodies, first trimester, fetus 1

O36.0112 Maternal care for anti-D [Rh] antibodies, first trimester, fetus 2

O36.0113 Maternal care for anti-D [Rh] antibodies, first trimester, fetus 3

O36.0114 Maternal care for anti-D [Rh] antibodies, first trimester, fetus 4

O36.0115 Maternal care for anti-D [Rh] antibodies, first trimester, fetus 5

O36.0119 Maternal care for anti-D [Rh] antibodies, first trimester, other fetus

O36.0120 Maternal care for anti-D [Rh] antibodies, second trimester, not applicable or unspecified

O36.0121 Maternal care for anti-D [Rh] antibodies, second trimester, fetus 1

O36.0122 Maternal care for anti-D [Rh] antibodies, second trimester, fetus 2

O36.0123 Maternal care for anti-D [Rh] antibodies, second trimester, fetus 3

O36.0124 Maternal care for anti-D [Rh] antibodies, second trimester, fetus 4

O36.0125 Maternal care for anti-D [Rh] antibodies, second trimester, fetus 5

O36.0129 Maternal care for anti-D [Rh] antibodies, second trimester, other fetus

O36.0130 Maternal care for anti-D [Rh] antibodies, third trimester, not applicable or unspecified

O36.0131 Maternal care for anti-D [Rh] antibodies, third trimester, fetus 1

O36.0132 Maternal care for anti-D [Rh] antibodies, third trimester, fetus 2

O36.0133 Maternal care for anti-D [Rh] antibodies, third trimester, fetus 3

O36.0134 Maternal care for anti-D [Rh] antibodies, third trimester, fetus 4

O36.0135 Maternal care for anti-D [Rh] antibodies, third trimester, fetus 5

O36.0139 Maternal care for anti-D [Rh] antibodies, third trimester, other fetus

O36.0191 Maternal care for anti-D [Rh] antibodies, unspecified trimester, fetus 1

O36.0190 Maternal care for anti-D [Rh] antibodies, unspecified trimester, not applicable or unspecified

O36.0192 Maternal care for anti-D [Rh] antibodies, unspecified trimester, fetus 2

O36.0193 Maternal care for anti-D [Rh] antibodies, unspecified trimester, fetus 3

O36.0194 Maternal care for anti-D [Rh] antibodies, unspecified trimester, fetus 4

O36.0195 Maternal care for anti-D [Rh] antibodies, unspecified trimester, fetus 5

O36.0199 Maternal care for anti-D [Rh] antibodies, unspecified trimester, other fetus

HCPCS Level II Code Number(s) and Narrative(s) N/A

Unhealthy Alcohol Use Screening and Behavioral Counseling Interventions
Unhealthy alcohol use screening is covered as a preventive service for all pregnant women. For adults who have a positive screening result for unhealthy alcohol use, behavioral counseling in a primary care setting is covered as a preventive service.

CPT Procedure Code Number(s) and Narrative(s)
99408, 99409
ICD-10 Diagnosis Code Number(s) and Narrative(s) N/A
HCPCS Level II Code Number(s) and Narrative(s) G0442 Annual alcohol misuse screening, 15 minutes

G0443 Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes

G2011 Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., audit, dast), and brief intervention, 5-14 minutes

OTHER FEMALE PREVENTIVE SCREENINGS

Hepatitis B Virus Screening
Hepatitis B virus (HBV) screening is covered as a preventive service when any of the following criteria are met:
  • Pregnant females
  • Asymptomatic adolescents and adults at high risk for HBV infection

High Risk Hepatitis B virus screening is defined by any of the following:
  • Foreign-born individuals whose country of origin has a high prevalence of Hepatitis B (2 percent or greater)
  • Individuals with a lack of vaccination in infancy in US-born infants with parents from high prevalence areas (8 percent or greater)
  • Individuals who are HIV positive
  • Individuals who are Injection drug users
  • Individuals who have contact with Hepatitis B infected individuals
  • Individuals who are receiving hemodialysis or cytotoxic treatment or immunosuppressive treatment
CPT Procedure Code Number(s) and Narrative(s)
80055, 80081, 86704, 86705, 86706, 87340, 87341

WHEN THE FOLLOWING CODES ARE REPORTED IN CONJUNCTION WITH HEPATITIS B VIRUS SCREENING, THEY ARE COVERED AS A PREVENTIVE SERVICE:

36415, 36416, 99000
ICD-10 Diagnosis Code Number(s) and Narrative(s) FOR HEPATITIS B VIRUS SCREENING, CPT CODES 86704, 86705, 86706, 87340, 87341 AND HCPCS CODE G0499 WILL ONLY BE COVERED AS A PREVENTIVE SERVICE FOR ANY APPROPRIATE PREGNANCY DIAGNOSIS CODE OR INCREASED RISK DIAGNOSIS CODE:

B20 Human immunodeficiency virus [HIV] disease

F11.10 Opioid abuse, uncomplicated

F11.120 Opioid abuse with intoxication, uncomplicated

F11.121 Opioid abuse with intoxication delirium

F11.122 Opioid abuse with intoxication with perceptual disturbance

F11.129 Opioid abuse with intoxication, unspecified

F11.14 Opioid abuse with opioid-induced mood disorder

F11.150 Opioid abuse with opioid-induced psychotic disorder with delusions

F11.151 Opioid abuse with opioid-induced psychotic disorder with hallucinations

F11.159 Opioid abuse with opioid-induced psychotic disorder, unspecified

F11.181 Opioid abuse with opioid-induced sexual dysfunction

F11.182 Opioid abuse with opioid-induced sleep disorder

F11.188 Opioid abuse with other opioid-induced disorder

F11.19 Opioid abuse with unspecified opioid-induced disorder

F11.20 Opioid dependence, uncomplicated

F11.220 Opioid dependence with intoxication, uncomplicated

F11.221 Opioid dependence with intoxication delirium

F11.222 Opioid dependence with intoxication with perceptual disturbance

F11.229 Opioid dependence with intoxication, unspecified

F11.23 Opioid dependence with withdrawal

F11.24 Opioid dependence with opioid-induced mood disorder

F11.250 Opioid dependence with opioid-induced psychotic disorder with delusions

F11.251 Opioid dependence with opioid-induced psychotic disorder with hallucinations

F11.259 Opioid dependence with opioid-induced psychotic disorder, unspecified

F11.281 Opioid dependence with opioid-induced sexual dysfunction

F11.282 Opioid dependence with opioid-induced sleep disorder

F11.288 Opioid dependence with other opioid-induced disorder

F11.29 Opioid dependence with unspecified opioid-induced disorder

F11.90 Opioid use, unspecified, uncomplicated

F11.920 Opioid use, unspecified with intoxication, uncomplicated

F11.921 Opioid use, unspecified with intoxication delirium

F11.922 Opioid use, unspecified with intoxication with perceptual disturbance

F11.929 Opioid use, unspecified with intoxication, unspecified

F11.93 Opioid use, unspecified with withdrawal

F11.94 Opioid use, unspecified with opioid-induced mood disorder

F11.950 Opioid use, unspecified with opioid-induced psychotic disorder with delusions

F11.951 Opioid use, unspecified with opioid-induced psychotic disorder with hallucinations

F11.959 Opioid use, unspecified with opioid-induced psychotic disorder, unspecified

F11.981 Opioid use, unspecified with opioid-induced sexual dysfunction

F11.982 Opioid use, unspecified with opioid-induced sleep disorder

F11.988 Opioid use, unspecified with other opioid-induced disorder

F11.99 Opioid use, unspecified with unspecified opioid-induced disorder

F13.10 Sedative, hypnotic or anxiolytic abuse, uncomplicated

F13.120 Sedative, hypnotic or anxiolytic abuse with intoxication, uncomplicated

F13.121 Sedative, hypnotic or anxiolytic abuse with intoxication delirium

F13.129 Sedative, hypnotic or anxiolytic abuse with intoxication, unspecified

F13.14 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced mood disorder

F13.150 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced psychotic disorder with delusions

F13.151 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced psychotic disorder with hallucinations

F13.159 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced psychotic disorder, unspecified

F13.180 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced anxiety disorder

F13.181 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced sexual dysfunction

F13.182 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-induced sleep disorder

F13.188 Sedative, hypnotic or anxiolytic abuse with other sedative, hypnotic or anxiolytic-induced disorder

F13.19 Sedative, hypnotic or anxiolytic abuse with unspecified sedative, hypnotic or anxiolytic-induced disorder

F13.20 Sedative, hypnotic or anxiolytic dependence, uncomplicated

F13.220 Sedative, hypnotic or anxiolytic dependence with intoxication, uncomplicated

F13.221 Sedative, hypnotic or anxiolytic dependence with intoxication delirium

F13.229 Sedative, hypnotic or anxiolytic dependence with intoxication, unspecified

F13.230 Sedative, hypnotic or anxiolytic dependence with withdrawal, uncomplicated

F13.231 Sedative, hypnotic or anxiolytic dependence with withdrawal delirium

F13.232 Sedative, hypnotic or anxiolytic dependence with withdrawal with perceptual disturbance

F13.239 Sedative, hypnotic or anxiolytic dependence with withdrawal, unspecified

F13.24 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced mood disorder

F13.250 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced psychotic disorder with delusions

F13.251 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced psychotic disorder with hallucinations

F13.259 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced psychotic disorder, unspecified

F13.26 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced persisting amnestic disorder

F13.27 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced persisting dementia

F13.280 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced anxiety disorder

F13.281 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced sexual dysfunction

F13.282 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or anxiolytic-induced sleep disorder

F13.288 Sedative, hypnotic or anxiolytic dependence with other sedative, hypnotic or anxiolytic-induced disorder

F13.29 Sedative, hypnotic or anxiolytic dependence with unspecified sedative, hypnotic or anxiolytic-induced disorder

F13.90 Sedative, hypnotic, or anxiolytic use, unspecified, uncomplicated

F13.920 Sedative, hypnotic or anxiolytic use, unspecified with intoxication, uncomplicated

F13.921 Sedative, hypnotic or anxiolytic use, unspecified with intoxication delirium

F13.929 Sedative, hypnotic or anxiolytic use, unspecified with intoxication, unspecified

F13.930 Sedative, hypnotic or anxiolytic use, unspecified with withdrawal, uncomplicated

F13.931 Sedative, hypnotic or anxiolytic use, unspecified with withdrawal delirium

F13.932 Sedative, hypnotic or anxiolytic use, unspecified with withdrawal with perceptual disturbances

F13.939 Sedative, hypnotic or anxiolytic use, unspecified with withdrawal, unspecified

F13.94 Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced mood disorder

F13.950 Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced psychotic disorder with delusions

F13.951 Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced psychotic disorder with hallucinations

F13.959 Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced psychotic disorder, unspecified

F13.96 Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced persisting amnestic disorder

F13.97 Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced persisting dementia

F13.980 Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced anxiety disorder

F13.981 Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced sexual dysfunction

F13.982 Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or anxiolytic-induced sleep disorder

F13.988 Sedative, hypnotic or anxiolytic use, unspecified with other sedative, hypnotic or anxiolytic-induced disorder

F13.99 Sedative, hypnotic or anxiolytic use, unspecified with unspecified sedative, hypnotic or anxiolytic-induced disorder

F14.10 Cocaine abuse, uncomplicated

F14.120 Cocaine abuse with intoxication, uncomplicated

F14.121 Cocaine abuse with intoxication with delirium

F14.122 Cocaine abuse with intoxication with perceptual disturbance

F14.129 Cocaine abuse with intoxication, unspecified

F14.14 Cocaine abuse with cocaine-induced mood disorder

F14.150 Cocaine abuse with cocaine-induced psychotic disorder with delusions

F14.151 Cocaine abuse with cocaine-induced psychotic disorder with hallucinations

F14.159 Cocaine abuse with cocaine-induced psychotic disorder, unspecified

F14.180 Cocaine abuse with cocaine-induced anxiety disorder

F14.181 Cocaine abuse with cocaine-induced sexual dysfunction

F14.182 Cocaine abuse with cocaine-induced sleep disorder

F14.188 Cocaine abuse with other cocaine-induced disorder

F14.19 Cocaine abuse with unspecified cocaine-induced disorder

F14.20 Cocaine dependence, uncomplicated

F14.220 Cocaine dependence with intoxication, uncomplicated

F14.221 Cocaine dependence with intoxication delirium

F14.222 Cocaine dependence with intoxication with perceptual disturbance

F14.229 Cocaine dependence with intoxication, unspecified

F14.23 Cocaine dependence with withdrawal

F14.24 Cocaine dependence with cocaine-induced mood disorder

F14.250 Cocaine dependence with cocaine-induced psychotic disorder with delusions

F14.251 Cocaine dependence with cocaine-induced psychotic disorder with hallucinations

F14.259 Cocaine dependence with cocaine-induced psychotic disorder, unspecified

F14.280 Cocaine dependence with cocaine-induced anxiety disorder

F14.281 Cocaine dependence with cocaine-induced sexual dysfunction

F14.282 Cocaine dependence with cocaine-induced sleep disorder

F14.288 Cocaine dependence with other cocaine-induced disorder

F14.29 Cocaine dependence with unspecified cocaine-induced disorder

F14.90 Cocaine use, unspecified, uncomplicated

F14.920 Cocaine use, unspecified with intoxication, uncomplicated

F14.921 Cocaine use, unspecified with intoxication delirium

F14.922 Cocaine use, unspecified with intoxication with perceptual disturbance

F14.929 Cocaine use, unspecified with intoxication, unspecified

F14.94 Cocaine use, unspecified with cocaine-induced mood disorder

F14.950 Cocaine use, unspecified with cocaine-induced psychotic disorder with delusions

F14.951 Cocaine use, unspecified with cocaine-induced psychotic disorder with hallucinations

F14.959 Cocaine use, unspecified with cocaine-induced psychotic disorder, unspecified

F14.980 Cocaine use, unspecified with cocaine-induced anxiety disorder

F14.981 Cocaine use, unspecified with cocaine-induced sexual dysfunction

F14.982 Cocaine use, unspecified with cocaine-induced sleep disorder

F14.988 Cocaine use, unspecified with other cocaine-induced disorder

F14.99 Cocaine use, unspecified with unspecified cocaine-induced disorder

F15.10 Other stimulant abuse, uncomplicated

F15.120 Other stimulant abuse with intoxication, uncomplicated

F15.121 Other stimulant abuse with intoxication delirium

F15.122 Other stimulant abuse with intoxication with perceptual disturbance

F15.129 Other stimulant abuse with intoxication, unspecified

F15.14 Other stimulant abuse with stimulant-induced mood disorder

F15.150 Other stimulant abuse with stimulant-induced psychotic disorder with delusions

F15.151 Other stimulant abuse with stimulant-induced psychotic disorder with hallucinations

F15.159 Other stimulant abuse with stimulant-induced psychotic disorder, unspecified

F15.180 Other stimulant abuse with stimulant-induced anxiety disorder

F15.181 Other stimulant abuse with stimulant-induced sexual dysfunction

F15.182 Other stimulant abuse with stimulant-induced sleep disorder

F15.188 Other stimulant abuse with other stimulant-induced disorder

F15.19 Other stimulant abuse with unspecified stimulant-induced disorder

F15.20 Other stimulant dependence, uncomplicated

F15.220 Other stimulant dependence with intoxication, uncomplicated

F15.221 Other stimulant dependence with intoxication delirium

F15.222 Other stimulant dependence with intoxication with perceptual disturbance

F15.229 Other stimulant dependence with intoxication, unspecified

F15.23 Other stimulant dependence with withdrawal

F15.24 Other stimulant dependence with stimulant-induced mood disorder

F15.250 Other stimulant dependence with stimulant-induced psychotic disorder with delusions

F15.251 Other stimulant dependence with stimulant-induced psychotic disorder with hallucinations

F15.259 Other stimulant dependence with stimulant-induced psychotic disorder, unspecified

F15.280 Other stimulant dependence with stimulant-induced anxiety disorder

F15.281 Other stimulant dependence with stimulant-induced sexual dysfunction

F15.282 Other stimulant dependence with stimulant-induced sleep disorder

F15.288 Other stimulant dependence with other stimulant-induced disorder

F15.29 Other stimulant dependence with unspecified stimulant-induced disorder

F15.90 Other stimulant use, unspecified, uncomplicated

F15.920 Other stimulant use, unspecified with intoxication, uncomplicated

F15.921 Other stimulant use, unspecified with intoxication delirium

F15.922 Other stimulant use, unspecified with intoxication with perceptual disturbance

F15.929 Other stimulant use, unspecified with intoxication, unspecified

F15.93 Other stimulant use, unspecified with withdrawal

F15.94 Other stimulant use, unspecified with stimulant-induced mood disorder

F15.950 Other stimulant use, unspecified with stimulant-induced psychotic disorder with delusions

F15.951 Other stimulant use, unspecified with stimulant-induced psychotic disorder with hallucinations

F15.959 Other stimulant use, unspecified with stimulant-induced psychotic disorder, unspecified

F15.980 Other stimulant use, unspecified with stimulant-induced anxiety disorder

F15.981 Other stimulant use, unspecified with stimulant-induced sexual dysfunction

F15.982 Other stimulant use, unspecified with stimulant-induced sleep disorder

F15.988 Other stimulant use, unspecified with other stimulant-induced disorder

F15.99 Other stimulant use, unspecified with unspecified stimulant-induced disorder

F19.10 Other psychoactive substance abuse, uncomplicated

F19.120 Other psychoactive substance abuse with intoxication, uncomplicated

F19.121 Other psychoactive substance abuse with intoxication delirium

F19.122 Other psychoactive substance abuse with intoxication with perceptual disturbances

F19.129 Other psychoactive substance abuse with intoxication, unspecified

F19.14 Other psychoactive substance abuse with psychoactive substance-induced mood disorder

F19.150 Other psychoactive substance abuse with psychoactive substance-induced psychotic disorder with delusions

F19.151 Other psychoactive substance abuse with psychoactive substance-induced psychotic disorder with hallucinations

F19.159 Other psychoactive substance abuse with psychoactive substance-induced psychotic disorder, unspecified

F19.16 Other psychoactive substance abuse with psychoactive substance-induced persisting amnestic disorder

F19.17 Other psychoactive substance abuse with psychoactive substance-induced persisting dementia

F19.180 Other psychoactive substance abuse with psychoactive substance-induced anxiety disorder

F19.181 Other psychoactive substance abuse with psychoactive substance-induced sexual dysfunction

F19.182 Other psychoactive substance abuse with psychoactive substance-induced sleep disorder

F19.188 Other psychoactive substance abuse with other psychoactive substance-induced disorder

F19.19 Other psychoactive substance abuse with unspecified psychoactive substance-induced disorder

Z00.00 Encounter for general adult medical examination without abnormal findings

Z00.01 Encounter for general adult medical examination with abnormal findings

Z00.121 Encounter for routine child health examination with abnormal findings

Z00.129 Encounter for routine child health examination without abnormal findings

Z01.411 Encounter for gynecological examination (general) (routine) with abnormal findings

Z01.419 Encounter for gynecological examination (general) (routine) without abnormal findings

Z11.3 Encounter for screening for infections with a predominantly sexual mode of transmission

Z11.59 Encounter for screening for other viral diseases

Z20.2 Contact with and (suspected) exposure to infections with a predominantly sexual mode of transmission

Z20.5 Contact with and (suspected) exposure to viral hepatitis

Z21 Asymptomatic human immunodeficiency virus

Z28.3 Underimmunization status

Z79.899 Other long term (current) drug therapy

Z92.21 Personal history of antineoplastic chemotherapy

Z92.25 Personal history of immunosupression therapy

Z99.2 Dependence on renal dialysis

HCPCS Level II Code Number(s) and Narrative(s) G0499 Hepatitis B screening in non-pregnant, high risk individual includes hepatitis B surface antigen (HBSAG) followed by a neutralizing confirmatory test for initially reactive results, and antibodies to HBSAG (anti-HBS) and hepatitis B core antigen (anti-HBC)

Human Papillomavirus (HPV) Screening
Human papillomavirus (HPV) screening is covered as a preventive service for all females ages 30 years and older every three years. In accordance with USPSTF recommendation, those who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing is covered every 5 years.

CPT Procedure Code Number(s) and Narrative(s) 87624, 87625

WHEN THE FOLLOWING CODE IS REPORTED IN CONJUNCTION WITH HUMAN PAPILLOMAVIRUS (HPV) SCREENING THAT IS CONSIDERED PREVENTIVE, IT IS CONSIDERED A PREVENTIVE SERVICE:

99000
ICD-10 Diagnosis Code Number(s) and Narrative(s) N/A
HCPCS Level II Code Number(s) and Narrative(s) N/A

Osteoporosis (Bone Mineral Density) Screening
Osteoporosis (bone mineral density) screening is covered as a preventive service every two years for females without a history of osteoporotic fracture or without a history of osteoporosis secondary to another condition who are ages 65 years and older or younger than 65 years who are at high risk for osteoporosis.
CPT Procedure Code Number(s) and Narrative(s)
76977, 77078, 77080, 77081
ICD-10 Diagnosis Code Number(s) and Narrative(s) Z13.820 Encounter for screening for osteoporosis
HCPCS Level II Code Number(s) and Narrative(s) G0130 Single energy x-ray absorptiometry (SEXA) bone density study, one or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel)

When the above procedure codes for osteoporosis screening come in with one of the following diagnosis codes, the procedure should not be considered preventive.

ICD-10 Diagnosis Code Number(s) and Narrative(s) FOR OSTEOPOROSIS (BONE MINERAL DENSITY) SCREENING, CPT CODES 76977, 77078, 77080, 77081 AND HCPCS G0130 WILL NOT BE COVERED AS A PREVENTIVE SERVICE FOR THE FOLLOWING DIAGNOSIS CODES:

M80.00XA Age-related osteoporosis with current pathological fracture, unspecified site, initial encounter for fracture

M80.00XD Age-related osteoporosis with current pathological fracture, unspecified site, subsequent encounter for fracture with routine healing

M80.00XG Age-related osteoporosis with current pathological fracture, unspecified site, subsequent encounter for fracture with delayed healing

M80.00XK Age-related osteoporosis with current pathological fracture, unspecified site, subsequent encounter for fracture with nonunion

M80.00XP Age-related osteoporosis with current pathological fracture, unspecified site, subsequent encounter for fracture with malunion

M80.00XS Age-related osteoporosis with current pathological fracture, unspecified site, sequela

M80.011A Age-related osteoporosis with current pathological fracture, right shoulder, initial encounter for fracture

M80.011D Age-related osteoporosis with current pathological fracture, right shoulder, subsequent encounter for fracture with routine healing

M80.011G Age-related osteoporosis with current pathological fracture, right shoulder, subsequent encounter for fracture with delayed healing

M80.011K Age-related osteoporosis with current pathological fracture, right shoulder, subsequent encounter for fracture with nonunion

M80.011P Age-related osteoporosis with current pathological fracture, right shoulder, subsequent encounter for fracture with malunion

M80.011S Age-related osteoporosis with current pathological fracture, right shoulder, sequela

M80.012A Age-related osteoporosis with current pathological fracture, left shoulder, initial encounter for fracture

M80.012D Age-related osteoporosis with current pathological fracture, left shoulder, subsequent encounter for fracture with routine healing

M80.012G Age-related osteoporosis with current pathological fracture, left shoulder, subsequent encounter for fracture with delayed healing

M80.012K Age-related osteoporosis with current pathological fracture, left shoulder, subsequent encounter for fracture with nonunion

M80.012P Age-related osteoporosis with current pathological fracture, left shoulder, subsequent encounter for fracture with malunion

M80.012S Age-related osteoporosis with current pathological fracture, left shoulder, sequela

M80.019A Age-related osteoporosis with current pathological fracture, unspecified shoulder, initial encounter for fracture

M80.019D Age-related osteoporosis with current pathological fracture, unspecified shoulder, subsequent encounter for fracture with routine healing

M80.019G Age-related osteoporosis with current pathological fracture, unspecified shoulder, subsequent encounter for fracture with delayed healing

M80.019K Age-related osteoporosis with current pathological fracture, unspecified shoulder, subsequent encounter for fracture with nonunion

M80.019P Age-related osteoporosis with current pathological fracture, unspecified shoulder, subsequent encounter for fracture with malunion

M80.019S Age-related osteoporosis with current pathological fracture, unspecified shoulder, sequela

M80.021A Age-related osteoporosis with current pathological fracture, right humerus, initial encounter for fracture

M80.021D Age-related osteoporosis with current pathological fracture, right humerus, subsequent encounter for fracture with routine healing

M80.021G Age-related osteoporosis with current pathological fracture, right humerus, subsequent encounter for fracture with delayed healing

M80.021K Age-related osteoporosis with current pathological fracture, right humerus, subsequent encounter for fracture with nonunion

M80.021P Age-related osteoporosis with current pathological fracture, right humerus, subsequent encounter for fracture with malunion

M80.021S Age-related osteoporosis with current pathological fracture, right humerus, sequela

M80.022A Age-related osteoporosis with current pathological fracture, left humerus, initial encounter for fracture

M80.022D Age-related osteoporosis with current pathological fracture, left humerus, subsequent encounter for fracture with routine healing

M80.022G Age-related osteoporosis with current pathological fracture, left humerus, subsequent encounter for fracture with delayed healing

M80.022K Age-related osteoporosis with current pathological fracture, left humerus, subsequent encounter for fracture with nonunion

M80.022P Age-related osteoporosis with current pathological fracture, left humerus, subsequent encounter for fracture with malunion

M80.022S Age-related osteoporosis with current pathological fracture, left humerus, sequela

M80.029A Age-related osteoporosis with current pathological fracture, unspecified humerus, initial encounter for fracture

M80.029D Age-related osteoporosis with current pathological fracture, unspecified humerus, subsequent encounter for fracture with routine healing

M80.029G Age-related osteoporosis with current pathological fracture, unspecified humerus, subsequent encounter for fracture with delayed healing

M80.029K Age-related osteoporosis with current pathological fracture, unspecified humerus, subsequent encounter for fracture with nonunion

M80.029P Age-related osteoporosis with current pathological fracture, unspecified humerus, subsequent encounter for fracture with malunion

M80.029S Age-related osteoporosis with current pathological fracture, unspecified humerus, sequela

M80.031A Age-related osteoporosis with current pathological fracture, right forearm, initial encounter for fracture

M80.031D Age-related osteoporosis with current pathological fracture, right forearm, subsequent encounter for fracture with routine healing

M80.031G Age-related osteoporosis with current pathological fracture, right forearm, subsequent encounter for fracture with delayed healing

M80.031K Age-related osteoporosis with current pathological fracture, right forearm, subsequent encounter for fracture with nonunion

M80.031P Age-related osteoporosis with current pathological fracture, right forearm, subsequent encounter for fracture with malunion

M80.031S Age-related osteoporosis with current pathological fracture, right forearm, sequela

M80.032A Age-related osteoporosis with current pathological fracture, left forearm, initial encounter for fracture

M80.032D Age-related osteoporosis with current pathological fracture, left forearm, subsequent encounter for fracture with routine healing

M80.032G Age-related osteoporosis with current pathological fracture, left forearm, subsequent encounter for fracture with delayed healing

M80.032K Age-related osteoporosis with current pathological fracture, left forearm, subsequent encounter for fracture with nonunion

M80.032P Age-related osteoporosis with current pathological fracture, left forearm, subsequent encounter for fracture with malunion

M80.032S Age-related osteoporosis with current pathological fracture, left forearm, sequela

M80.039A Age-related osteoporosis with current pathological fracture, unspecified forearm, initial encounter for fracture

M80.039D Age-related osteoporosis with current pathological fracture, unspecified forearm, subsequent encounter for fracture with routine healing

M80.039G Age-related osteoporosis with current pathological fracture, unspecified forearm, subsequent encounter for fracture with delayed healing

M80.039K Age-related osteoporosis with current pathological fracture, unspecified forearm, subsequent encounter for fracture with nonunion

M80.039P Age-related osteoporosis with current pathological fracture, unspecified forearm, subsequent encounter for fracture with malunion

M80.039S Age-related osteoporosis with current pathological fracture, unspecified forearm, sequela

M80.041A Age-related osteoporosis with current pathological fracture, right hand, initial encounter for fracture

M80.041D Age-related osteoporosis with current pathological fracture, right hand, subsequent encounter for fracture with routine healing

M80.041G Age-related osteoporosis with current pathological fracture, right hand, subsequent encounter for fracture with delayed healing

M80.041K Age-related osteoporosis with current pathological fracture, right hand, subsequent encounter for fracture with nonunion

M80.041P Age-related osteoporosis with current pathological fracture, right hand, subsequent encounter for fracture with malunion

M80.041S Age-related osteoporosis with current pathological fracture, right hand, sequela

M80.042A Age-related osteoporosis with current pathological fracture, left hand, initial encounter for fracture

M80.042D Age-related osteoporosis with current pathological fracture, left hand, subsequent encounter for fracture with routine healing

M80.042G Age-related osteoporosis with current pathological fracture, left hand, subsequent encounter for fracture with delayed healing

M80.042K Age-related osteoporosis with current pathological fracture, left hand, subsequent encounter for fracture with nonunion

M80.042P Age-related osteoporosis with current pathological fracture, left hand, subsequent encounter for fracture with malunion

M80.042S Age-related osteoporosis with current pathological fracture, left hand, sequela

M80.049A Age-related osteoporosis with current pathological fracture, unspecified hand, initial encounter for fracture

M80.049D Age-related osteoporosis with current pathological fracture, unspecified hand, subsequent encounter for fracture with routine healing

M80.049G Age-related osteoporosis with current pathological fracture, unspecified hand, subsequent encounter for fracture with delayed healing

M80.049K Age-related osteoporosis with current pathological fracture, unspecified hand, subsequent encounter for fracture with nonunion

M80.049P Age-related osteoporosis with current pathological fracture, unspecified hand, subsequent encounter for fracture with malunion

M80.049S Age-related osteoporosis with current pathological fracture, unspecified hand, sequela

M80.051A Age-related osteoporosis with current pathological fracture, right femur, initial encounter for fracture

M80.051D Age-related osteoporosis with current pathological fracture, right femur, subsequent encounter for fracture with routine healing

M80.051G Age-related osteoporosis with current pathological fracture, right femur, subsequent encounter for fracture with delayed healing

M80.051K Age-related osteoporosis with current pathological fracture, right femur, subsequent encounter for fracture with nonunion

M80.051P Age-related osteoporosis with current pathological fracture, right femur, subsequent encounter for fracture with malunion

M80.051S Age-related osteoporosis with current pathological fracture, right femur, sequela

M80.052A Age-related osteoporosis with current pathological fracture, left femur, initial encounter for fracture

M80.052D Age-related osteoporosis with current pathological fracture, left femur, subsequent encounter for fracture with routine healing

M80.052G Age-related osteoporosis with current pathological fracture, left femur, subsequent encounter for fracture with delayed healing

M80.052K Age-related osteoporosis with current pathological fracture, left femur, subsequent encounter for fracture with nonunion

M80.052P Age-related osteoporosis with current pathological fracture, left femur, subsequent encounter for fracture with malunion

M80.052S Age-related osteoporosis with current pathological fracture, left femur, sequela

M80.059A Age-related osteoporosis with current pathological fracture, unspecified femur, initial encounter for fracture

M80.059D Age-related osteoporosis with current pathological fracture, unspecified femur, subsequent encounter for fracture with routine healing

M80.059G Age-related osteoporosis with current pathological fracture, unspecified femur, subsequent encounter for fracture with delayed healing

M80.059K Age-related osteoporosis with current pathological fracture, unspecified femur, subsequent encounter for fracture with nonunion

M80.059P Age-related osteoporosis with current pathological fracture, unspecified femur, subsequent encounter for fracture with malunion

M80.059S Age-related osteoporosis with current pathological fracture, unspecified femur, sequela

M80.061A Age-related osteoporosis with current pathological fracture, right lower leg, initial encounter for fracture

M80.061D Age-related osteoporosis with current pathological fracture, right lower leg, subsequent encounter for fracture with routine healing

M80.061G Age-related osteoporosis with current pathological fracture, right lower leg, subsequent encounter for fracture with delayed healing

M80.061K Age-related osteoporosis with current pathological fracture, right lower leg, subsequent encounter for fracture with nonunion

M80.061P Age-related osteoporosis with current pathological fracture, right lower leg, subsequent encounter for fracture with malunion

M80.061S Age-related osteoporosis with current pathological fracture, right lower leg, sequela

M80.062A Age-related osteoporosis with current pathological fracture, left lower leg, initial encounter for fracture

M80.062D Age-related osteoporosis with current pathological fracture, left lower leg, subsequent encounter for fracture with routine healing

M80.062G Age-related osteoporosis with current pathological fracture, left lower leg, subsequent encounter for fracture with delayed healing

M80.062K Age-related osteoporosis with current pathological fracture, left lower leg, subsequent encounter for fracture with nonunion

M80.062P Age-related osteoporosis with current pathological fracture, left lower leg, subsequent encounter for fracture with malunion

M80.062S Age-related osteoporosis with current pathological fracture, left lower leg, sequela

M80.069A Age-related osteoporosis with current pathological fracture, unspecified lower leg, initial encounter for fracture

M80.069D Age-related osteoporosis with current pathological fracture, unspecified lower leg, subsequent encounter for fracture with routine healing

M80.069G Age-related osteoporosis with current pathological fracture, unspecified lower leg, subsequent encounter for fracture with delayed healing

M80.069K Age-related osteoporosis with current pathological fracture, unspecified lower leg, subsequent encounter for fracture with nonunion

M80.069P Age-related osteoporosis with current pathological fracture, unspecified lower leg, subsequent encounter for fracture with malunion

M80.069S Age-related osteoporosis with current pathological fracture, unspecified lower leg, sequela

M80.071A Age-related osteoporosis with current pathological fracture, right ankle and foot, initial encounter for fracture

M80.071D Age-related osteoporosis with current pathological fracture, right ankle and foot, subsequent encounter for fracture with routine healing

M80.071G Age-related osteoporosis with current pathological fracture, right ankle and foot, subsequent encounter for fracture with delayed healing

M80.071K Age-related osteoporosis with current pathological fracture, right ankle and foot, subsequent encounter for fracture with nonunion

M80.071P Age-related osteoporosis with current pathological fracture, right ankle and foot, subsequent encounter for fracture with malunion

M80.071S Age-related osteoporosis with current pathological fracture, right ankle and foot, sequela

M80.072A Age-related osteoporosis with current pathological fracture, left ankle and foot, initial encounter for fracture

M80.072D Age-related osteoporosis with current pathological fracture, left ankle and foot, subsequent encounter for fracture with routine healing

M80.072G Age-related osteoporosis with current pathological fracture, left ankle and foot, subsequent encounter for fracture with delayed healing

M80.072K Age-related osteoporosis with current pathological fracture, left ankle and foot, subsequent encounter for fracture with nonunion

M80.072P Age-related osteoporosis with current pathological fracture, left ankle and foot, subsequent encounter for fracture with malunion

M80.072S Age-related osteoporosis with current pathological fracture, left ankle and foot, sequela

M80.079A Age-related osteoporosis with current pathological fracture, unspecified ankle and foot, initial encounter for fracture

M80.079D Age-related osteoporosis with current pathological fracture, unspecified ankle and foot, subsequent encounter for fracture with routine healing

M80.079G Age-related osteoporosis with current pathological fracture, unspecified ankle and foot, subsequent encounter for fracture with delayed healing

M80.079K Age-related osteoporosis with current pathological fracture, unspecified ankle and foot, subsequent encounter for fracture with nonunion

M80.079P Age-related osteoporosis with current pathological fracture, unspecified ankle and foot, subsequent encounter for fracture with malunion

M80.079S Age-related osteoporosis with current pathological fracture, unspecified ankle and foot, sequela

M80.08XA Age-related osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture

M80.08XD Age-related osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with routine healing

M80.08XG Age-related osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with delayed healing

M80.08XK Age-related osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with nonunion

M80.08XP Age-related osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with malunion

M80.08XS Age-related osteoporosis with current pathological fracture, vertebra(e), sequela

M80.80XA Other osteoporosis with current pathological fracture, unspecified site, initial encounter for fracture

M80.80XD Other osteoporosis with current pathological fracture, unspecified site, subsequent encounter for fracture with routine healing

M80.80XG Other osteoporosis with current pathological fracture, unspecified site, subsequent encounter for fracture with delayed healing

M80.80XK Other osteoporosis with current pathological fracture, unspecified site, subsequent encounter for fracture with nonunion

M80.80XP Other osteoporosis with current pathological fracture, unspecified site, subsequent encounter for fracture with malunion

M80.80XS Other osteoporosis with current pathological fracture, unspecified site, sequela

M80.811A Other osteoporosis with current pathological fracture, right shoulder, initial encounter for fracture

M80.811D Other osteoporosis with current pathological fracture, right shoulder, subsequent encounter for fracture with routine healing

M80.811G Other osteoporosis with current pathological fracture, right shoulder, subsequent encounter for fracture with delayed healing

M80.811K Other osteoporosis with current pathological fracture, right shoulder, subsequent encounter for fracture with nonunion

M80.811P Other osteoporosis with current pathological fracture, right shoulder, subsequent encounter for fracture with malunion

M80.811S Other osteoporosis with current pathological fracture, right shoulder, sequela

M80.812A Other osteoporosis with current pathological fracture, left shoulder, initial encounter for fracture

M80.812D Other osteoporosis with current pathological fracture, left shoulder, subsequent encounter for fracture with routine healing

M80.812G Other osteoporosis with current pathological fracture, left shoulder, subsequent encounter for fracture with delayed healing

M80.812K Other osteoporosis with current pathological fracture, left shoulder, subsequent encounter for fracture with nonunion

M80.812P Other osteoporosis with current pathological fracture, left shoulder, subsequent encounter for fracture with malunion

M80.812S Other osteoporosis with current pathological fracture, left shoulder, sequela

M80.819A Other osteoporosis with current pathological fracture, unspecified shoulder, initial encounter for fracture

M80.819D Other osteoporosis with current pathological fracture, unspecified shoulder, subsequent encounter for fracture with routine healing

M80.819G Other osteoporosis with current pathological fracture, unspecified shoulder, subsequent encounter for fracture with delayed healing

M80.819K Other osteoporosis with current pathological fracture, unspecified shoulder, subsequent encounter for fracture with nonunion

M80.819P Other osteoporosis with current pathological fracture, unspecified shoulder, subsequent encounter for fracture with malunion

M80.819S Other osteoporosis with current pathological fracture, unspecified shoulder, sequela

M80.821A Other osteoporosis with current pathological fracture, right humerus, initial encounter for fracture

M80.821D Other osteoporosis with current pathological fracture, right humerus, subsequent encounter for fracture with routine healing

M80.821G Other osteoporosis with current pathological fracture, right humerus, subsequent encounter for fracture with delayed healing

M80.821K Other osteoporosis with current pathological fracture, right humerus, subsequent encounter for fracture with nonunion

M80.821P Other osteoporosis with current pathological fracture, right humerus, subsequent encounter for fracture with malunion

M80.821S Other osteoporosis with current pathological fracture, right humerus, sequela

M80.822A Other osteoporosis with current pathological fracture, left humerus, initial encounter for fracture

M80.822D Other osteoporosis with current pathological fracture, left humerus, subsequent encounter for fracture with routine healing

M80.822G Other osteoporosis with current pathological fracture, left humerus, subsequent encounter for fracture with delayed healing

M80.822K Other osteoporosis with current pathological fracture, left humerus, subsequent encounter for fracture with nonunion

M80.822P Other osteoporosis with current pathological fracture, left humerus, subsequent encounter for fracture with malunion

M80.822S Other osteoporosis with current pathological fracture, left humerus, sequela

M80.829A Other osteoporosis with current pathological fracture, unspecified humerus, initial encounter for fracture

M80.829D Other osteoporosis with current pathological fracture, unspecified humerus, subsequent encounter for fracture with routine healing

M80.829G Other osteoporosis with current pathological fracture, unspecified humerus, subsequent encounter for fracture with delayed healing

M80.829K Other osteoporosis with current pathological fracture, unspecified humerus, subsequent encounter for fracture with nonunion

M80.829P Other osteoporosis with current pathological fracture, unspecified humerus, subsequent encounter for fracture with malunion

M80.829S Other osteoporosis with current pathological fracture, unspecified humerus, sequela

M80.831A Other osteoporosis with current pathological fracture, right forearm, initial encounter for fracture

M80.831D Other osteoporosis with current pathological fracture, right forearm, subsequent encounter for fracture with routine healing

M80.831G Other osteoporosis with current pathological fracture, right forearm, subsequent encounter for fracture with delayed healing

M80.831K Other osteoporosis with current pathological fracture, right forearm, subsequent encounter for fracture with nonunion

M80.831P Other osteoporosis with current pathological fracture, right forearm, subsequent encounter for fracture with malunion

M80.831S Other osteoporosis with current pathological fracture, right forearm, sequela

M80.832A Other osteoporosis with current pathological fracture, left forearm, initial encounter for fracture

M80.832D Other osteoporosis with current pathological fracture, left forearm, subsequent encounter for fracture with routine healing

M80.832G Other osteoporosis with current pathological fracture, left forearm, subsequent encounter for fracture with delayed healing

M80.832K Other osteoporosis with current pathological fracture, left forearm, subsequent encounter for fracture with nonunion

M80.832P Other osteoporosis with current pathological fracture, left forearm, subsequent encounter for fracture with malunion

M80.832S Other osteoporosis with current pathological fracture, left forearm, sequela

M80.839A Other osteoporosis with current pathological fracture, unspecified forearm, initial encounter for fracture

M80.839D Other osteoporosis with current pathological fracture, unspecified forearm, subsequent encounter for fracture with routine healing

M80.839K Other osteoporosis with current pathological fracture, unspecified forearm, subsequent encounter for fracture with nonunion

M80.841A Other osteoporosis with current pathological fracture, right hand, initial encounter for fracture

M80.841D Other osteoporosis with current pathological fracture, right hand, subsequent encounter for fracture with routine healing

M80.841G Other osteoporosis with current pathological fracture, right hand, subsequent encounter for fracture with delayed healing

M80.841K Other osteoporosis with current pathological fracture, right hand, subsequent encounter for fracture with nonunion

M80.841P Other osteoporosis with current pathological fracture, right hand, subsequent encounter for fracture with malunion

M80.841S Other osteoporosis with current pathological fracture, right hand, sequela

M80.842A Other osteoporosis with current pathological fracture, left hand, initial encounter for fracture

M80.842D Other osteoporosis with current pathological fracture, left hand, subsequent encounter for fracture with routine healing

M80.842G Other osteoporosis with current pathological fracture, left hand, subsequent encounter for fracture with delayed healing

M80.842K Other osteoporosis with current pathological fracture, left hand, subsequent encounter for fracture with nonunion

M80.842P Other osteoporosis with current pathological fracture, left hand, subsequent encounter for fracture with malunion

M80.842S Other osteoporosis with current pathological fracture, left hand, sequela

M80.849A Other osteoporosis with current pathological fracture, unspecified hand, initial encounter for fracture

M80.849D Other osteoporosis with current pathological fracture, unspecified hand, subsequent encounter for fracture with routine healing

M80.849G Other osteoporosis with current pathological fracture, unspecified hand, subsequent encounter for fracture with delayed healing

M80.849K Other osteoporosis with current pathological fracture, unspecified hand, subsequent encounter for fracture with nonunion

M80.849P Other osteoporosis with current pathological fracture, unspecified hand, subsequent encounter for fracture with malunion

M80.849S Other osteoporosis with current pathological fracture, unspecified hand, sequela

M80.851A Other osteoporosis with current pathological fracture, right femur, initial encounter for fracture

M80.851D Other osteoporosis with current pathological fracture, right femur, subsequent encounter for fracture with routine healing

M80.851G Other osteoporosis with current pathological fracture, right femur, subsequent encounter for fracture with delayed healing

M80.851K Other osteoporosis with current pathological fracture, right femur, subsequent encounter for fracture with nonunion

M80.851P Other osteoporosis with current pathological fracture, right femur, subsequent encounter for fracture with malunion

M80.851S Other osteoporosis with current pathological fracture, right femur, sequela

M80.852A Other osteoporosis with current pathological fracture, left femur, initial encounter for fracture

M80.852D Other osteoporosis with current pathological fracture, left femur, subsequent encounter for fracture with routine healing

M80.852G Other osteoporosis with current pathological fracture, left femur, subsequent encounter for fracture with delayed healing

M80.852K Other osteoporosis with current pathological fracture, left femur, subsequent encounter for fracture with nonunion

M80.852P Other osteoporosis with current pathological fracture, left femur, subsequent encounter for fracture with malunion

M80.852S Other osteoporosis with current pathological fracture, left femur, sequela

M80.859A Other osteoporosis with current pathological fracture, unspecified femur, initial encounter for fracture

M80.859D Other osteoporosis with current pathological fracture, unspecified femur, subsequent encounter for fracture with routine healing

M80.859G Other osteoporosis with current pathological fracture, unspecified femur, subsequent encounter for fracture with delayed healing

M80.859K Other osteoporosis with current pathological fracture, unspecified femur, subsequent encounter for fracture with nonunion

M80.859P Other osteoporosis with current pathological fracture, unspecified femur, subsequent encounter for fracture with malunion

M80.859S Other osteoporosis with current pathological fracture, unspecified femur, sequela

M80.861A Other osteoporosis with current pathological fracture, right lower leg, initial encounter for fracture

M80.861D Other osteoporosis with current pathological fracture, right lower leg, subsequent encounter for fracture with routine healing

M80.861G Other osteoporosis with current pathological fracture, right lower leg, subsequent encounter for fracture with delayed healing

M80.861K Other osteoporosis with current pathological fracture, right lower leg, subsequent encounter for fracture with nonunion

M80.861P Other osteoporosis with current pathological fracture, right lower leg, subsequent encounter for fracture with malunion

M80.861S Other osteoporosis with current pathological fracture, right lower leg, sequela

M80.862A Other osteoporosis with current pathological fracture, left lower leg, initial encounter for fracture

M80.862D Other osteoporosis with current pathological fracture, left lower leg, subsequent encounter for fracture with routine healing

M80.862G Other osteoporosis with current pathological fracture, left lower leg, subsequent encounter for fracture with delayed healing

M80.862K Other osteoporosis with current pathological fracture, left lower leg, subsequent encounter for fracture with nonunion

M80.862P Other osteoporosis with current pathological fracture, left lower leg, subsequent encounter for fracture with malunion

M80.862S Other osteoporosis with current pathological fracture, left lower leg, sequela

M80.869A Other osteoporosis with current pathological fracture, unspecified lower leg, initial encounter for fracture

M80.869D Other osteoporosis with current pathological fracture, unspecified lower leg, subsequent encounter for fracture with routine healing

M80.869G Other osteoporosis with current pathological fracture, unspecified lower leg, subsequent encounter for fracture with delayed healing

M80.869K Other osteoporosis with current pathological fracture, unspecified lower leg, subsequent encounter for fracture with nonunion

M80.869P Other osteoporosis with current pathological fracture, unspecified lower leg, subsequent encounter for fracture with malunion

M80.869S Other osteoporosis with current pathological fracture, unspecified lower leg, sequela

M80.871A Other osteoporosis with current pathological fracture, right ankle and foot, initial encounter for fracture

M80.871D Other osteoporosis with current pathological fracture, right ankle and foot, subsequent encounter for fracture with routine healing

M80.871G Other osteoporosis with current pathological fracture, right ankle and foot, subsequent encounter for fracture with delayed healing

M80.871K Other osteoporosis with current pathological fracture, right ankle and foot, subsequent encounter for fracture with nonunion

M80.871P Other osteoporosis with current pathological fracture, right ankle and foot, subsequent encounter for fracture with malunion

M80.871S Other osteoporosis with current pathological fracture, right ankle and foot, sequela

M80.872A Other osteoporosis with current pathological fracture, left ankle and foot, initial encounter for fracture

M80.872D Other osteoporosis with current pathological fracture, left ankle and foot, subsequent encounter for fracture with routine healing

M80.872G Other osteoporosis with current pathological fracture, left ankle and foot, subsequent encounter for fracture with delayed healing

M80.872K Other osteoporosis with current pathological fracture, left ankle and foot, subsequent encounter for fracture with nonunion

M80.872P Other osteoporosis with current pathological fracture, left ankle and foot, subsequent encounter for fracture with malunion

M80.872S Other osteoporosis with current pathological fracture, left ankle and foot, sequela

M80.879A Other osteoporosis with current pathological fracture, unspecified ankle and foot, initial encounter for fracture

M80.879D Other osteoporosis with current pathological fracture, unspecified ankle and foot, subsequent encounter for fracture with routine healing

M80.879G Other osteoporosis with current pathological fracture, unspecified ankle and foot, subsequent encounter for fracture with delayed healing

M80.879K Other osteoporosis with current pathological fracture, unspecified ankle and foot, subsequent encounter for fracture with nonunion

M80.879P Other osteoporosis with current pathological fracture, unspecified ankle and foot, subsequent encounter for fracture with malunion

M80.879S Other osteoporosis with current pathological fracture, unspecified ankle and foot, sequela

M80.88XA Other osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture

M80.88XD Other osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with routine healing

M80.88XG Other osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with delayed healing

M80.88XK Other osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with nonunion

M80.88XP Other osteoporosis with current pathological fracture, vertebra(e), subsequent encounter for fracture with malunion

M80.88XS Other osteoporosis with current pathological fracture, vertebra(e), sequela

M81.0 Age-related osteoporosis without current pathological fracture

M81.6 Localized osteoporosis [Lequesne]

M81.8 Other osteoporosis without current pathological fracture



THERAPY AND COUNSELING

SERVICES INCLUDED AS PART OF THE COMPREHENSIVE PREVENTIVE EXAM OR WELL-WOMAN VISIT
The following services are covered as part of a preventive exam, or well-woman visit as appropriate, and are not eligible for separate reimbursement:
  • Primary Care Interventions to Promote and Support Breastfeeding
  • Discussion of Chemoprevention for Breast Cancer
  • Instruction on fertility awareness-based methods, including the lactation amenorrhea method
  • Intimate Partner Violence Screening
  • Urinary Incontinence Screening

TOBACCO USE COUNSELING
Augmented pregnancy-tailored counseling for tobacco use is covered as a preventive service for all pregnant females who smoke tobacco products.

CPT Procedure Code Number(s) and Narrative(s)
99406, 99407
ICD-10 Diagnosis Code Number(s) and Narrative(s) N/A
HCPCS Level II Code Number(s) and Narrative(s) N/A


MEDICATION
Medications listed below are considered preventive when prescribed by a health care provider. For members without a pharmacy benefit, the following medications will be covered under their medical benefit if preventive criteria are met. Coverage of preventive medications under the member's medical benefit is contingent on the member submitting a receipt for the preventive medication. Cost-share may be applied to the branded preventive medication if there is an alternative generic medication available, unless a healthcare provider determines the generic is medically inappropriate.

LOW DOSE ASPIRIN FOR PREECLAMPSIA
Low-dose aspirin (81mg/d) is covered as a preventive service for pregnant females who are at high risk for preeclampsia after 12 weeks of gestation.

BREAST CANCER CHEMOPREVENTION
Breast cancer chemoprevention (i.e. tamoxifen 20mg) is covered as a preventive service for asymptomatic females 35 years or older without a prior diagnosis of breast cancer, ductal carcinoma in situ, or lobular carcinoma in situ, who are at high risk for breast cancer and at low risk for adverse effects from breast cancer chemoprevention.

FOLIC ACID
Daily folic acid supplements (0.4 to 0.8 mg [400 to 800 g]) are covered as a preventive service for all females planning or capable of pregnancy.

MISCELLANEOUS

REPRODUCTIVE EDUCATION AND COUNSELING, CONTRACEPTION, AND STERILIZATION
Sterilization procedures, patient education and counseling for contraception, and all Food and Drug Administration (FDA)--approved contraceptive methods are covered as a preventive service for all females with reproductive capacity.

Contraceptive methods identified by FDA for females include:
  • sterilization procedures
  • implantable rod/capsule
  • intrauterine device (IUD) copper
  • IUD with progestin
  • hormone injection for contraception
  • hormone releasing patch for contraception
  • vaginal contraceptive ring
  • diaphragm
  • sponge
  • cervical cap
  • female condom
  • spermicide
  • emergency contraception
  • oral contraceptives

For members without a pharmacy benefit, contraceptives that are typically obtained at a retail pharmacy may be covered under their medical benefit

Contraception services related to follow-up and management of side effects, counseling for continued adherence, and for device removal will be covered as a preventive service for all females.

*Please refer to 07.10.05 Noncontraceptive Use of the Levonorgestrel-Releasing Intrauterine System for coverage of contraceptives for noncontraceptive uses.
CPT Procedure Code Number(s) and Narrative(s)
11976, 11981, 11982, 11983, 57170, 58300, 58301, 58565, 58600, 58605, 58611, 58615, 58670, 58671

THE FOLLOWING CODES ARE CONSIDERED PREVENTIVE WHEN REPORTED 3-4 MONTHS POST FALLOPIAN TUBE OCCLUSION (58565) WHEN REPORTED WITH THE APPROPRIATE DIAGNOSIS CODE:

58340, 74740

THE FOLLOWING CODE IS CONSIDERED PREVENTIVE WHEN BILLED WITH THE APPROPRIATE PREVENTIVE ICD-9 DIAGNOSIS CODE OR IN CONJUNCTION WITH HCPCS CODE J1050:

96372

THE FOLLOWING CODES SHOULD BE USED TO REPORT REPRODUCTIVE EDUCATION OR CONTRACEPTIVE COUNSELING:

99401, 99402, 99403, 99404
ICD-10 Diagnosis Code Number(s) and Narrative(s) FOR CONTRACEPTION/STERILIZATION, CPT CODES 11976, 11981, 11982, 11983. 58300, AND 58301, AND HCPCS CODES J1050, J7296, J7297, J7300, J7301, J7303, J7304, J7306, J7307, S4989, AND S4993 WILL ONLY BE COVERED AS A PREVENTIVE SERVICE FOR THE FOLLOWING DIAGNOSIS CODES:

Z01.411 Encounter for gynecological examination (general) (routine) with abnormal findings

Z01.419 Encounter for gynecological examination (general) (routine) without abnormal findings

Z30.011 Encounter for initial prescription of contraceptive pills

Z30.012 Encounter for prescription of emergency contraception

Z30.013 Encounter for initial prescription of injectable contraceptive

Z30.014 Encounter for initial prescription of intrauterine contraceptive device

Z30.015 Encounter for initial prescription of vaginal ring hormonal contraceptive

Z30.016 Encounter for initial prescription of transdermal patch hormonal contraceptive device

Z30.017 Encounter for initial prescription of implantable subdermal contraceptive

Z30.018 Encounter for initial prescription of other contraceptives

Z30.019 Encounter for initial prescription of contraceptives, unspecified

Z30.02 Counseling and instruction in natural family planning to avoid pregnancy

Z30.09 Encounter for other general counseling and advice on contraception

Z30.2 Encounter for sterilization

Z30.40 Encounter for surveillance of contraceptives, unspecified

Z30.41 Encounter for surveillance of contraceptive pills

Z30.42 Encounter for surveillance of injectable contraceptive

Z30.430 Encounter for insertion of intrauterine contraceptive device

Z30.431 Encounter for routine checking of intrauterine contraceptive device

Z30.432 Encounter for removal of intrauterine contraceptive device

Z30.433 Encounter for removal and reinsertion of intrauterine contraceptive device

Z30.44 Encounter for surveillance of vaginal ring hormonal contraceptive device

Z30.45 Encounter for surveillance of transdermal patch hormonal contraceptive device

Z30.46 Encounter for surveillance of implantable subdermal contraceptive

Z30.49 Encounter for surveillance of other contraceptives

Z30.8 Encounter for other contraceptive management

Z30.9 Encounter for contraceptive management, unspecified

FOR CONTRACEPTION/STERILIZATION, CPT CODE 96372 WILL ONLY BE COVERED AS A PREVENTIVE SERVICE FOR THE FOLLOWING CONDITIONS:

Z01.411 Encounter for gynecological examination (general) (routine) with abnormal findings

Z01.419 Encounter for gynecological examination (general) (routine) without abnormal findings

Z30.012 Encounter for prescription of emergency contraception

Z30.013 Encounter for initial prescription of injectable contraceptive

Z30.018 Encounter for initial prescription of other contraceptives

Z30.019 Encounter for initial prescription of contraceptives, unspecified

Z30.02 Counseling and instruction in natural family planning to avoid pregnancy

Z30.09 Encounter for other general counseling and advice on contraception

Z30.2 Encounter for sterilization

Z30.40 Encounter for surveillance of contraceptives, unspecified

Z30.42 Encounter for surveillance of injectable contraceptive

Z30.49 Encounter for surveillance of other contraceptives

Z30.8 Encounter for other contraceptive management

Z30.9 Encounter for contraceptive management, unspecified

FOR FALLOPIAN TUBE OCCLUSION, CPT CODES 58340 AND 74740 WILL ONLY BE COVERED AS A PREVENTIVE SERVICE FOR THE FOLLOWING CONDITIONS:

Z30.8 Encounter for other contraceptive management

Z30.40 Encounter for surveillance of contraceptives, unspecified

Z30.49 Encounter for surveillance of other contraceptives

HCPCS Level II Code Number(s) and Narrative(s) A4261 Cervical cap for contraceptive use

A4264 Permanent implantable contraceptive intratubal occlusion devices(s) and delivery system

A4266 Diaphragm for contraceptive use

A4268 Contraceptive supply, condom, female, each

A4269 Contraceptive supply, spermicide (e.g., foam, gel), each

J1050 Injection, medroxyprogesterone acetate, 1 mg

J7296 Levonorgestrel-releasing intrauterine contraceptive system, (kyleena), 19.5 mg

J7297 Levonorgestrel-releasing intrauterine contraceptive system (liletta), 52 mg

J7298 Levonorgestrel-releasing intrauterine contraceptive system (mirena), 52 mg

J7300 Intrauterine copper contraceptive

J7301 Levonorgestrel-releasing intrauterine contraceptive system (skyla), 13.5 mg

J7303 Contraceptive supply, hormone containing vaginal ring, each

J7304 Contraceptive supply, hormone containing patch, each

J7306 Levonorgestrel (contraceptive) implant system, including implants and supplies

J7307 Etonogestrel (contraceptive) implant system, including implant and supplies

S4981 Insertion of levonorgestrel-releasing intrauterine system

S4989 Contraceptive intrauterine device (e.g. progestacert IUD), including implants and supplies

S4993 Contraceptive pills for birth control

Associated Services for Contraceptive Surgery
Supplies and additional services associated with tubal ligation will be considered preventive when billed with a tubal ligation procedure such as, but not limited to, the following:
  • Anesthesia
  • Antibiotics
  • Pathology/Laboratory services

Payment for these services will be based on providers' contract.

Supplies listed in the table are considered preventive when billed with an appropriate contraceptive surgery code.

CPT Procedure Code Number(s) and Narrative(s)
00840, 00851, 00940, 00952, 62322, 62323, 62326, 62327, 64435, 80048, 80050, 80051, 80053, 81001, 81002, 81003, 81015, 81025, 82565, 82575, 82947, 82948, 84132, 84520, 84703, 85004, 85007, 85014, 85018, 85025, 85027, 85048, 85610, 85730, 88302, 93000, 94760, 96360, 96365, 96366, 96372
ICD-10 Diagnosis Code Number(s) and Narrative(s) N/A
HCPCS Level II Code Number(s) and Narrative(s) J0461 Injection, atropine sulfate, 0.01 mg

J0670 Injection, mepivacaine HCl, per 10 ml

J0690 Injection, cefazolin sodium, 500 mg

J1094 Injection, dexamethasone acetate, 1 mg

J1100 Injection, dexamethasone sodium phosphate, 1 mg

J1810 Injection, droperidol and fentanyl citrate, up to 2 ml ampule

J1885 Injection, ketorolac tromethamine, per 15 mg

J2001 Injection, lidocaine HCl for intravenous infusion, 10 mg

J2175 Injection, meperidine HCl, per 100 mg

J2180 Injection, meperidine and promethazine HCl, up to 50 mg

J2250 Injection, midazolam HCl, per 1 mg

J2300 Injection, nalbuphine HCl, per 10 mg

J2405 Injection, ondansetron HCl, per 1 mg

J2550 Injection, promethazine HCl, up to 50 mg

J2710 Injection, neostigmine methylsulfate, up to 0.5 mg

J2765 Injection, metoclopramide HCl, up to 10 mg

J2795 Injection, ropivacaine HCl, 1 mg

J3010 Injection, fentanyl citrate, 0.1 mg

J3410 Injection, hydroxyzine HCl, up to 25 mg

J7040 Infusion, normal saline solution, sterile (500 ml = 1 unit)

J7050 Infusion, normal saline solution, 250 cc

J7120 Ringer's lactate infusion, up to 1,000 cc

J7636 Atropine, inhalation solution, compounded product, administered through dme, unit dose form, per milligram

J7643 Glycopyrrolate, inhalation solution, compounded product, administered through dme, unit dose form, per milligram

S0020 Injection, bupivicaine HCl, 30 ml

S1015 IV tubing extension set

S5011 5% dextrose in lactated ringer's, 1000 ml

Revenue Code Number(s) and Narrative(s)0250 Pharmacy - general classification

0251 Pharmacy - generic drugs

0258 Pharmacy - IV solutions

0260 IV therapy - general classification

0261 IV therapy - infusion pump

0263 IV therapy – therapy/drug/supply delivery

0270 Medical/surgical supplies and devices - general classification

0271 Medical/surgical supplies and devices-non sterile supply

0272 Medical/surgical supplies and devices-sterile supply

0310 Laboratory pathological-general classification

0314 Laboratory pathological-biopsy

0370 Anesthesia - general classification

0710 Recovery room-general classification

0963 Professional fees-anesthesiologist (MD)

0964 Professional fees - Anesthetist (CRNA)

0983 Professional fees - clinic


BREASTFEEDING SUPPORT/COUNSELING AND SUPPLIES
Comprehensive lactation support/counseling is covered as a preventive service for females during pregnancy and during the postpartum period.

Breastfeeding supplies are covered as a preventive service for the duration of breastfeeding.

For additional information refer to medical policy 05.00.76- Breast Pumps.

CPT Procedure Code Number(s) and Narrative(s) 99401, 99402, 99403, 99404, 99411, 99412, 99501
ICD-10 Diagnosis Code Number(s) and Narrative(s) FOR BREASTFEEDING SUPPLIES/SUPPORT/COUNSELING, CPT CODE 99501 WILL ONLY BE COVERED AS A PREVENTIVE SERVICE FOR THE FOLLOWING DIAGNOSIS CODE:

Z39.1 Encounter for care and examination of lactating mother
HCPCS Level II Code Number(s) and Narrative(s) A4281 Tubing for breast pump, replacement

A4282 Adapter for breast pump, replacement

A4283 Cap for breast pump bottle, replacement

A4284 Breast shield and splash protector for use with breast pump, replacement

A4285 Polycarbonate bottle for use with breast pump, replacement

A4286 Locking ring for breast pump, replacement

E0602 Breast pump, manual, any type

E0603 Breast pump, electric (AC and/or DC), any type

E0604 Breast pump, hospital grade, electric (AC and/or DC), any type

S9443 Lactation classes, nonphysician provider, per session

PROLONGED PREVENTIVE SERVICES

Prolonged preventive services are covered as a preventive service in the office or other outpatient setting when billed as an add-on to an applicable preventive service.

CPT Procedure Code Number(s) and Narrative(s) N/A
ICD-10 Diagnosis Code Number(s) and Narrative(s) N/A
HCPCS Level II Code Number(s) and Narrative(s) G0513 Prolonged preventive service(s) (beyond the typical service time of the primary procedure), in the office or other outpatient setting requiring direct patient contact beyond the usual service; first 30 minutes (list separately in addition to code for preventive service)

G0514 Prolonged preventive service(s) (beyond the typical service time of the primary procedure), in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes (list separately in addition to code G0513 for additional 30 minutes of preventive service)

Version Effective Date: 01/01/2020
Version Issued Date: 12/31/2019
Version Reissued Date: N/A

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.