Notification



Notification Issue Date:



Policy Attachment


Attachment to Policy # 00.06.02ab


Attachment:C

Policy #:00.06.02ab

Description:Pediatric 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 pediatric preventive services for individuals or groups for whom these services apply.

Some of the pediatric preventive services are recommended for individuals up to 21 years of age. The preventive services are organized as follows:

PEDIATRIC PREVENTIVE CARE SERVICES
  • Visits
    • Prebirth Exams
    • Preventive Exams
  • Screenings
    • Alcohol and Drug Use Screening and Behavioral Counseling Intervention
    • Autism and Developmental Screening
    • Bilirubin Screening
    • Chlamydia Screening
    • Depression Screening
    • Dyslipidemia Screening
    • Gonorrhea Screening
    • Hearing Screening for Newborns
    • Hearing Screening (All children 29 days or older)
    • Hepatitis B Virus Screening
    • Human Immunodeficiency Virus (HIV) Screening
    • Iron Deficiency Anemia Screening
    • Lead Poisoning Screening
    • Newborn Screening Panel
    • Syphilis Screening
    • Vision Screening
  • Additional Screening Services and Counseling
    • Behavioral Counseling for Prevention of Sexually Transmitted Infections
    • Obesity Screening and Behavioral Counseling
    • Recommended Services Included as Part of the Comprehensive Preventive Evaluation and Management Exam or Newborn Care
      • Behavioral Counseling for Skin Cancer Prevention
      • Blood Pressure Screening
      • Congenital Heart Defect Screening
      • Counseling and Education Provided by Healthcare Providers to Prevent Initiation of Tobacco Use
      • Developmental Surveillance
      • Obesity Screening
      • Psychosocial/Behavioral Assessment
  • Medication
    • Fluoride
    • Prophylactic Ocular Topical Medication for Gonorrhea
  • Miscellaneous
    • Fluoride Varnish Application
    • Immunizations
    • Prolonged Preventive Services
    • Tuberculosis Testing

VISITS

PREBIRTH VISITS
Prebirth visits are covered as a preventive service for all expectant parents for the purpose of establishing a pediatric medical home.

CPT Procedure Code Number(s) and Narrative(s)
99401, 99402, 99403, 99404
ICD-10 Diagnosis Code Number(s) and Narrative(s) Z76.81 Expectant parent(s) prebirth pediatrician visit
HCPCS Level II Code Number(s) and Narrative(s) N/A

PREVENTIVE EXAMS
Preventive exams are covered as a preventive service for all children up to 21 years of age.

For pediatric preventive exams schedule please refer to the Bright Futures/American Academy of Pediatrics Preventive Recommendations: https://www.aap.org/en-us/professional-resources/practice-support/Periodicity/Periodicity%20Schedule_FINAL.pdf.
CPT Procedure Code Number(s) and Narrative(s)
99381, 99382, 99383, 99384, 99385, 99391, 99392, 99393, 99394, 99395
ICD-10 Diagnosis Code Number(s) and Narrative(s) N/A
HCPCS Level II Code Number(s) and Narrative(s) N/A

SCREENINGS

ALCOHOL AND DRUG USE SCREENING AND BEHAVIORAL COUNSELING INTERVENTION
Annual alcohol and drug use screening is covered as a preventive service for children 11 years and older. For children who have a positive screening result for alcohol or drug use/misuse, annual behavioral counseling in a primary care setting is also 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

AUTISM AND DEVELOPMENTAL SCREENING
In accordance with the preventive exam age schedule set forth by American Academy of Pediatrics (AAP)/Bright Futures, autism and developmental screening is covered as a preventive service.

CPT Procedure Code Number(s) and Narrative(s) 96110
ICD-10 Diagnosis Code Number(s) and Narrative(s) N/A
HCPCS Level II Code Number(s) and Narrative(s) N/A

BILIRUBIN SCREENING
Bilirubin screening is covered as a preventive service for all newborns at the newborn visit.

CPT Procedure Code Number(s) and Narrative(s) 82247, 88720

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

36415, 36416, 99000
ICD-10 Diagnosis Code Number(s) and Narrative(s) FOR BILIRUBIN SCREENING, CPT CODES 82247 AND 88720 WILL ONLY BE COVERED AS PREVENTIVE FOR THE FOLLOWING DIAGNOSIS CODE:

Z13.228 Encounter for screening for other metabolic disorders
HCPCS Level II Code Number(s) and Narrative(s) N/A

CHLAMYDIA SCREENING
Chlamydia screening is covered as a preventive service for all sexually active children up to age 21 years whose sexual history reveals new or persistent risk factors since the last negative test result .

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, 86332, 87110, 87270, 87320, 87490, 87491, 87810 WILL ONLY BE COVERED AS A PREVENTIVE SERVICE FOR THE FOLLOWING 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

DEPRESSION SCREENING
Depression screening is covered as a preventive service for children ages 12 years to 21 years. If depression screening is less than 15 minutes, it is considered part of a preventive evaluation and management exam.

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 CODE:

Z13.31 Encounter for screening for depression
HCPCS Level II Code Number(s) and Narrative(s) G0444 Annual depression screening, 15 minutes

DYSLIPIDEMIA SCREENING
In accordance with the preventive exam age schedule set forth by American Academy of Pediatrics (AAP)/Bright Futures, dyslipidemia risk assessment is covered as part of the preventive exam, to determine if dyslipidemia laboratory testing is indicated.

Following a positive risk assessment, or in those individuals where laboratory testing is indicated at specific age milestones, dyslipidemia laboratory screening is covered as a preventive service for children.

CPT Procedure Code Number(s) and Narrative(s) 80061, 82465, 83718, 83721, 84478

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

36415, 36416, 99000
ICD-10 Diagnosis Code Number(s) and Narrative(s) FOR DYSLIPIDEMIA SCREENING, CPT CODES 80061, 82465, 83718, AND 84478 WILL ONLY BE COVERED AS PREVENTIVE 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

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

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

Z13.220 Encounter for screening for lipoid disorders
HCPCS Level II Code Number(s) and Narrative(s) N/A

GONORRHEA SCREENING
Gonorrhea screening is covered as a preventive service for all sexually active children up to age 21 years whose sexual history reveals new or persistent risk factors since the last negative test result .

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 THE FOLLOWING 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

HEARING SCREENING FOR NEWBORNS
Hearing screening is covered as a preventive service for all newborns.

CPT Procedure Code Number(s) and Narrative(s) 92558
ICD-10 Diagnosis Code Number(s) and Narrative(s) N/A
HCPCS Level II Code Number(s) and Narrative(s) N/A

HEARING SCREENING (ALL CHILDREN 29 DAYS OR OLDER)
In accordance with the preventive exam age schedule set forth by American Academy of Pediatrics (AAP)/Bright Futures, hearing risk assessment is covered as part of the preventive exam, to determine if hearing screening is indicated.

Following a positive risk assessment, or in those individuals where hearing screening is indicated at specific age milestones, hearing screening is covered as a preventive service.

CPT Procedure Code Number(s) and Narrative(s)
92551, 92552, 92567
ICD-10 Diagnosis Code Number(s) and Narrative(s) FOR HEARING SCREENING, CPT CODES 92551, 92552, AND 92567 AND HCPCS V5008 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

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

Z00.129 Encounter for routine child health examination without abnormal findings
HCPCS Level II Code Number(s) and Narrative(s) V5008 Hearing screening

HEPATITIS B VIRUS SCREENING
Hepatitis B screening is covered as a preventive service for all asymptomatic adolescents 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
  • Males who have sex with other males
  • Individuals who are receiving hemodialysis or cytotoxic treatment or immunosuppressive treatment
CPT Procedure Code Number(s) and Narrative(s)
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 G0499 WILL ONLY BE COVERED AS A PREVENTIVE SERVICE FOR THE FOLLOWING 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

Z72.52 High risk homosexual behavior

Z72.53 High risk bisexual behavior

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 IMMUNODEFICIENCY VIRUS (HIV) SCREENING
Human immunodeficiency virus (HIV) screening is covered as a preventive service for children 15 to 18 years of age. HIV screening is covered as a preventive services for individuals younger than 15 years of age who are at increased risk for HIV.
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 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

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

Z11.4 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

IRON DEFICIENCY ANEMIA SCREENING
In accordance with the preventive exam age schedule set forth by American Academy of Pediatrics (AAP)/Bright Futures, iron deficiency anemia screening is covered as a preventive service for children 21 years or younger.

CPT Procedure Code Number(s) and Narrative(s) 85014, 85018

WHEN THE FOLLOWING CODES ARE REPORTED IN CONJUNCTION WITH A PREVENTIVE HEMOGLOBIN/HEMATOCRIT TEST, THEY ARE COVERED AS A PREVENTIVE SERVICE:

36415, 36416, 99000
ICD-10 Diagnosis Code Number(s) and Narrative(s) 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

Z13.0 Encounter for screening for diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism
HCPCS Level II Code Number(s) and Narrative(s) N/A

LEAD POISONING SCREENING
In accordance with the preventive exam age schedule set forth by American Academy of Pediatrics (AAP)/Bright Futures, lead poisoning screening is covered as a preventive service for children at risk of lead exposure.

CPT Procedure Code Number(s) and Narrative(s) 83655

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

36415, 36416, 99000
ICD-10 Diagnosis Code Number(s) and Narrative(s) FOR LEAD POISONING SCREENING, CPT CODE 83655 WILL ONLY BE CONSIDERED PREVENTIVE FOR THE FOLLOWING DIAGNOSIS CODES:

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

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

Z13.88 Encounter for screening for disorder due to exposure to contaminants
HCPCS Level II Code Number(s) and Narrative(s) N/A

NEWBORN SCREENING PANEL
Newborn screening panel (e.g., hemoglobin, endocrine, and other disorders) is covered as a preventive service for all newborns. Individual state mandates determine the screening tests that are included in the newborn screening panel. The panel may include, but is not limited to, the following tests:
  • Organic acidemia disorders
  • Fatty acid oxidation disorders
  • Amino acid disorders, including maple syrup urine disease, homocystinuria, and/or classic phenylketonuria
  • Endocrine disorders, including primary congenital hypothyroidism and/or congenital adrenal hyperplasia
  • Hemoglobin disorders, including sickle cell anemia and/or beta-thalassemia
  • Other disorders, including cystic fibrosis, spinal muscular atrophy, and/or classic galactosemia
CPT Procedure Code Number(s) and Narrative(s) WHEN THE FOLLOWING CODES ARE REPORTED IN CONJUNCTION WITH NEWBORN SCREENING PANEL, 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) S3620 Newborn screening panel, includes test kit, postage and the laboratory tests specified by the state for inclusion in this panel (eg, galactose; hemoglobin, electrophoresis; hydroxyprogesterone, 17-d; phenylanine (PKU); and thyroxine, total)

SYPHILIS SCREENING
Syphilis screening is covered as a preventive service for all sexually active children up to age 21 years who are at increased risk for infection.

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) 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 THE FOLLOWING 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

    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

VISION SCREENING
In accordance with the preventive exam age schedule set forth by American Academy of Pediatrics (AAP)/Bright Futures, vision screening is covered for all individuals 21 years of age or younger.
CPT Procedure Code Number(s) and Narrative(s) 99173, 99174, 99177
ICD-10 Diagnosis Code Number(s) and Narrative(s) FOR VISION SCREENING, CPT CODE 99173 AND 99174 WILL ONLY BE COVERED AS A PREVENTIVE SERVICE FOR THE FOLLOWING DIAGNOSIS CODES:

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

Z00.129 Encounter for routine child health examination without abnormal findings
HCPCS Level II Code Number(s) and Narrative(s) N/A

ADDITIONAL SCREENING SERVICES AND COUNSELING

BEHAVIORAL COUNSELING FOR PREVENTION OF SEXUALLY TRANSMITTED INFECTIONS
Behavioral counseling for prevention of sexually transmitted infections is covered as a preventive service semiannually for all sexually active adolescents at increased risk for sexually transmitted infections.

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) G0445 Semiannual high intensity behavioral counseling to prevent STIs, individual, face-to-face, includes education skills training & guidance on how to change sexual behavior

OBESITY SCREENING AND BEHAVIORAL COUNSELING
Obesity screening is covered as part of the preventive exam for all children 6 years of age and older. For children with an age- and sex-specific body mass index (BMI) in the 95th percentile or greater, counseling is covered as a preventive service. If the individual requires less than 15 minutes of counseling, it is considered part of the preventive exam. If the counseling is 15 minutes or more, the appropriate obesity counseling codes should be reported. Healthcare providers should offer or refer children with an age- and sex-specific BMI in the 95th percentile or greater for intensive, multi-component behavioral interventions.

CPT Procedure Code Number(s) and Narrative(s) N/A
ICD-10 Diagnosis Code Number(s) and Narrative(s) FOR BEHAVIORAL COUNSELING FOR OBESITY, G0447 WILL BE COVERED AS A PREVENTIVE SERVICE WITH THE FOLLOWING DIAGNOSIS CODE:

Z68.54 Body mass index (BMI) pediatric, greater than or equal to 95th percentile for age
HCPCS Level II Code Number(s) and Narrative(s) G0447 Face-to-face behavioral counseling for obesity, 15 minutes

SERVICES INCLUDED AS PART OF THE COMPREHENSIVE PREVENTIVE EXAM OR NEWBORN CARE
The following services are covered as part of a preventive exam, or newborn care services as appropriate, and are not eligible for separate reimbursement:
  • Behavioral Counseling for Skin Cancer Prevention
  • Blood Pressure Screening
  • Congenital Heart Defect Screening
  • Counseling and Education Provided by Healthcare Providers to Prevent Initiation of Tobacco Use
  • Developmental surveillance
  • Obesity Screening
  • Psychosocial/Behavioral Assessment


MEDICATION
Medications listed below are considered preventive when prescribed by a health care provider. For members without a pharmacy benefit, these medications may 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.

FLUORIDE
In accordance with the preventive exam age schedule set forth by American Academy of Pediatrics (AAP)/Bright Futures, oral fluoride, up to 0.5mg is covered as a preventive service for children ages 6 months to 16 years of age whose water supply is deficient in fluoride.

PROPHYLACTIC OCULAR TOPICAL MEDICATION FOR GONORRHEA
Prophylactic ocular topical medication for gonorrhea is covered as a preventive service for all newborns within 24 hours after birth. Prophylactic ocular topical medication for gonorrhea is included as part of a newborn's care.

MISCELLANEOUS

FLUORIDE VARNISH APPLICATION
Fluoride varnish application by primary care providers is covered as a preventive service for all infants and children twice a year starting at age of primary tooth eruption to 5 years of age.

CPT Procedure Code Number(s) and Narrative(s) 99188
ICD-10 Diagnosis Code Number(s) and Narrative(s) N/A
HCPCS Level II Code Number(s) and Narrative(s) N/A

IMMUNIZATIONS
In accordance with the Advisory Committee on Immunization Practices (ACIP) routine immunization recommendations, routine immunizations and their administration are covered as a preventive service for all children.

For the immunization’s schedule refer to medical policy 08.01.04, Immunizations.

CPT Procedure Code Number(s) and Narrative(s) 90620, 90621, 90630, 90632, 90633, 90636, 90644, 90647, 90648, 90651, 90653, 90654, 90655, 90656, 90657, 90658, 90660, 90661, 90662, 90670, 90673, 90674, 90680, 90681, 90682, 90685, 90686, 90687, 90688, 90689, 90694. 90696, 90698, 90700, 90702, 90707, 90710, 90713, 90714, 90715, 90716, 90723, 90732, 90733, 90734, 90736, 90739, 90740, 90743, 90744, 90746, 90747, 90748, 90756

IMMUNIZATION ADMINISTRATION

90460, 90461, 90471, 90472, 90473, 90474
ICD-10 Diagnosis Code Number(s) and Narrative(s) N/A
HCPCS Level II Code Number(s) and Narrative(s) Q2034 Influenza virus vaccine, split virus, for intramuscular use (Agriflu)

Q2035 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (AFLURIA)

Q2036 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (FLULAVAL)

Q2037 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (FLUVIRIN)

Q2038 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (FLUZONE)

IMMUNIZATION ADMINISTRATION

G0008 Administration of influenza virus vaccine

G0009 Administration of pneumococcal vaccine

G0010 Administration of hepatitis B vaccine

J3530 Nasal vaccine inhalation


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)


TUBERCULOSIS TESTING
In accordance with the preventive exam age schedule set forth by American Academy of Pediatrics (AAP)/Bright Futures, tuberculosis testing is covered for all individuals 21 years of age or younger.

CPT Procedure Code Number(s) and Narrative(s) 86580

THE FOLLOWING CODE WILL BE COVERED AS A PREVENTIVE SERVICE WHEN REPORTED FOR THE FOLLOW-UP TO READ THE TUBERCULOSIS TEST RESULTS:

99211
ICD-10 Diagnosis Code Number(s) and Narrative(s) FOR TUBERCULOSIS TESTING, CPT CODE 99211 WILL ONLY BE COVERED AS A PREVENTIVE SERVICE FOR THE FOLLOWING DIAGNOSIS CODES:

R76.11 Nonspecific reaction to tuberculin skin test without active tuberculosis

Z11.1 Encounter for screening for respiratory tuberculosis
HCPCS Level II Code Number(s) and Narrative(s) N/A

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.