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Preventive Care Services
00.06.02ba

​

Policy

State mandates do not automatically apply to all plans; therefore, individual benefits must be verified.​

Subject to the terms of the member's benefit contract, $0 cost share will be applied when the preventive service is performed at a participating provider, and there is specific direction from regulatory laws, such as the Affordable Care Act, to adjudicate the preventive service claim at $0 cost share.

The services listed in this policy are considered preventive care services when the criteria in this policy are met, when they are identified as preventive services in the Company’s benefit contracts, when they are mandated by state or federal law, or when they are included as a recommendation in any of the following:
  • US Preventive Services Task Force (USPSTF), A and B Recommendations
  • Health Resources and Services Administration (HRSA), American Academy of Pediatrics/Bright Futures
  • Centers for Disease Control and Prevention (CDC), Advisory Committee for Immunization Practices (ACIP), as well as professional society guidelines (i.e., American Academy of Pediatrics (​AAP), American Academy of Family Physicians (AAFP), ​American College of Obstetricians and Gynecologists (ACOG), American College of Physicians (ACP))​, Adult and Pediatric Immunization Schedules
  • US Department of Health and Human Services Secretary's Advisory Committee on Heritable Disorders in Newborns and Children
  • US Department of Health and Human Services, Women's Preventive Services: Required Health Plan Coverage Guidelines Supported by the Health Resources and Services Administration
Changes to coverage and cost-sharing requirements based on a new or updated recommendation or guideline will go into effect the first plan year beginning on or after the date that is 1 year after the effective date of the new recommendation or guideline.

When a recommendation or guideline for a preventive service is downgraded in the middle of a plan year, coverage for the preventive service will continue to apply through the end of the plan year, except in certain limited circumstances, such as significant safety concerns with the downgraded preventive service or a drop from an "A" or "B" USPSTF recommendation to a "D" USPSTF recommendation.

Cost-share (i.e., copayment, deductible, coinsurance) application is in accordance with the terms of the member's benefit contract.

The preventive services are organized within this policy as follows:

ADULT PREVENTIVE SERVICES (ATTACHMENT A)
  • Visits
    • Preventive Exams
      • Behavioral Counseling for Skin Cancer Prevention
      • High Blood Pressure Screening (Office-based)
      • Obesity Screening
      • Unhealthy drug use screening ​
  • Screenings
    • Abdominal Aortic Aneurysm (AAA) Screening
    • ​Anxiety Screening
    • Prediabetes and Type 2 Diabetes Mellitus Screening and Preventive Interventions
    • Colorectal Cancer Screening
      • Services performed in connection with a preventive colorectal cancer screening procedure
    • Depression ​and Suicide Risk Screening
    • Hepatitis B Virus Screening
    • Hepatitis C Virus Screening
    • High Blood Pressure Screening
    • Human Immunodeficiency Virus (HIV) Screening
    • Latent Tuberculosis Infection Screening
    • Lung Cancer Screening
    • Syphilis Screening
    • Unhealthy Alcohol Use Screening and Behavioral Counseling Interventions
  • Therapy and Counseling
    • Behavioral Counseling for Prevention of Sexually Transmitted Infections
    • Behavioral Interventions for Weight Loss ​to Prevent Obesity-related Morbidity and Mortality​
    • Exercise Interventions for the Prevention of Falls
    • Behavioral Counseling to Promote a Healthful Diet and Physical Activities for Cardiovascular Disease Prevention
    • Nutritional Counseling for Weight Management
    • Tobacco Use Counseling
    • Work-up and Follow-up Services for Pre-Exposure Prophylaxis for the Prevention of HIV
  • Medications
    • Pre-exposure Prophylaxis for the Prevention of HIV Infection
    • Prescription Bowel Preparation Medication
    • Statins for the Primary Prevention of Cardiovascular Disease
      • ​Lipid Disorder Screening​
    • Tobacco cessation medication
  • Miscellaneous
    • Routine Vaccines
    • Prolonged Preventive Services
FEMALE PREVENTIVE SERVICES (ATTACHMENT B)
  • Visits
    • Postpartum Care Visits
    • Prenatal Care Visits
    • Well-woman visits
      • Primary Care Interventions to Promote and Support Breastfeeding
      • Discussion of Chemoprevention for Breast Cancer
      • Instruction in fertility awareness-based methods, including the lactation amenorrhea method
      • Intimate Partner and Domestic Violence Screening and Counseling
      • Patient Navigation Services for Breast and Cervical Cancer Screening
      • Urinary Incontinence Screening
      • Counseling for the Prevention of Obesity​
  • Screenings
    • Sexually Transmitted Infections Screenings
      • Chlamydia ​and Gonorrhea Screening
      • Human Immunodeficiency Virus (HIV) Screening​
      • Syphilis Screening
    • Cancer Screenings
      • Breast and Ovarian Cancer Screenings, Genetic Risk Assessment Counseling, and BRCA Mutation Testing
      • Breast Cancer Screening (Mammography)
      • Cervical Cancer Screening
    • Pregnancy-related Screenings
      • Bacteriuria Screening
      • Counseling Interventions to Prevent Perinatal Depression
      • Depression ​and Suicide Risk Screening
      • Diabetes Screening after Pregnancy
      • Gestational Diabetes Mellitus Screening
      • RhD Incompatibility Screening
      • Unhealthy Alcohol Use Screening and Behavioral Counseling Interventions
    • Other Preventive Screenings
      • Anxiety Screening​
      • Hepatitis B Virus Screening
      • Human Papilloma Virus (HPV) Screening
      • Osteoporosis (Bone Mineral Density) Screening
  • Therapy and Counseling
    • ​Behavioral Counseling for Prevention of Sexually Transmitted Infections
    • Tobacco Use Screening and Counseling
  • Medication
    • Low-dose Aspirin for Pre-eclampsia
    • Breast Cancer Preventive Medicine
    • Folic Acid
  • Miscellaneous
    • Reproductive Education and Counseling, Contraception, and Sterilization
      • Associated Services for Contraceptives
    • Breastfeeding Support/Counseling and Supplies
    • Prolonged Preventive Services
    • Patient Navigation Services for Breast and Cervical Cancer Screening
PEDIATRIC PREVENTIVE SERVCES (ATTACHMENT C)
  • Visits
    • Pediatric Prenatal Exams
    • Preventive Exams
      • 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
      • High Body Mass Screening
      • Risk Assessment of Sudden Cardiac Arrest and Sudden Cardiac Death​
  • Screenings
    • Alcohol Use/Misuse Screening and Behavioral Counseling Intervention
    • Anxiety Screening
    • Autism and Developmental Screening
    • Behavioral/Social/Emotional Screening
    • Bilirubin Screening
    • Chlamydia ​and Gonorrhea Screening
    • Depression ​and Suicide Risk Screening
    • Dyslipidemia 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
    • Nutritional Counseling for Weight Management
    • HIgh Body Mass Behavioral Counseling Interventions
  • Medication
    • Fluoride
    • Prophylactic Ocular Topical Medication for Gonorrhea
  • Miscellaneous
    • Fluoride Varnish Application
    • Hemoglobin/Hematocrit Testing
    • Routine Vaccines 
    • Prolonged Preventive Services
    • Tuberculosis Testing
TRANSGENDER OR GENDER-DIVERSE PREVENTIVE SERVICES

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

Guidelines

This policy is consistent with applicable state and federal mandates, including the Patient Protection and Affordable Care Act (PPACA) of 2010 and the Health Care and Education Reconciliation Act (HCERA) of 2010.

Coverage is subject to the terms and conditions of the applicable benefit plan. Individual benefits must be verified.

Description

Preventive care services generally describe health care services performed to defend against illness or detect the early warning signs of health problems, including preventive visits, screenings, therapy and counseling, appropriate immunizations, contraception, and other laboratory tests.

References

Department of Health and Human Services. Centers for Disease Control and Prevention (CDC). Vaccines and Immunizations. Recommendations and Guidelines: Advisory Committee on Immunization Practices (ACIP). Available at: Advisory Committee on Immunization Practices (ACIP) | ACIP | CDC. Accessed April 7, 2026. 

Recommendations for Preventive Pediatric Health Care/Bright Futures. American Academy of Pediatrics. Available at: https://www.aap.org/en/practice-management/care-delivery-approaches/periodicity-schedule/​. Accessed April 7, 2026. 

Recommended Preventive Services. HealthCare.gov. Available at: https://www.healthcare.gov/what-are-my-preventive-care-benefits/. Accessed April 7, 2026. 

Unnanuntana A, Gladnick BP, Donnelly E, Lane JM. Current concepts review: the assessment of fracture risk. J Bone Joint Surg Am. 2010;92:743-53.

US Department of Health and Human Services. Secretary's Advisory Committee on Heritable disorders in Newborns and Children. Available at: http://www.hrsa.gov/advisorycommittees/mchbadvisory/heritabledisorders/. Accessed April 7, 2026.  

US Department of Health and Human Services. Women's Preventive Services: Required Health Plan Coverage Guidelines Supported by the Health Resources and Services Administration. Available at: https://www.hrsa.gov/womens-guidelines/index.html. Accessed April 7, 2026. 


US Department of Labor. Affordable Care Act Frequently Asked Questions website. Available at: https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/affordable-care-act/for-employers-and-advisers/aca-implementation-faqs. Accessed April 7, 2026. 

US Preventive Services Task Force. Available at: http://www.uspreventiveservicestaskforce.org/. Accessed April 7, 2026.   

Vaccines Licensed for Use in the United States. U.S. Food and Drug Administration. Available at: https://www.fda.gov/biologicsbloodvaccines/vaccines/approvedproducts/ucm093833.htm. Accessed April 7, 2026.  


Women's Recommendations. Women's Preventive Services Initiative. Available at: https://www.womenspreventivehealth.org/recommendations/. Accessed April 7, 2026. ​

Coding

CPT Procedure Code Number(s)
See Attachments A, B, and C.
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
See Attachments A, B, and C.
HCPCS Level II Code Number(s)
See Attachments A, B, and C.
Revenue Code Number(s)
N/A



Coding and Billing Requirements

Policy History

Revisions From 00.06.02ba:
10/01/2026

Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.
 

This policy has been identified for the ICD-10 code update, effective 10/01/2026.

 

The following ICD-10 CM  codes have been added to Attachment A and Attachment B of this policy:

BEHAVIORAL COUNSELING FOR PREVENTION OF SEXUALLY TRANSMITTED INFECTIONS:

F64.A Gender identity disorder, in remission

Z87.8901 Personal history of social gender transition

Z87.8902 Personal history of medical gender transition

Z87.8903 Personal history of surgical gender transition

Z87.8904 Personal history of intersex surgery

Z87.8909 Personal history of unspecified gender transition

Z87.893 Personal history of gender detransition​​

 

The following ICD-10 CM code has been termed (no longer valid code) from

Attachment A and Attachment B of this policy:

BEHAVIORAL COUNSELING FOR PREVENTION OF SEXUALLY TRANSMITTED INFECTIONS

Z87.890 Personal history of sex reassignment


Revisions From 00.06.02az:​
07/01/2026

This version of the policy will become effective 07/01/2026

 

The following updates have been made:


Attachment B:Female Preventive Care Services

Human Papillomavirus (HPV) Screening:

As previously communicated in a Newsflash article (Preventive Coverage Update of Human Papillomavirus (HPV) Screening for Commercial members​ (Retroactively Effective 01/01/2025), the following CPT code was added: 87626


Chlamydia and Gonorrhea Screening​

The following CPT code has been added: 87494


Attachment C: Pediatric Preventive Care Services


Chlamydia and Gonorrhea Screening​

The following CPT code has been added: 87494​


Hepatitis B Virus Screening

The following risk factor was added in accordance with the Centers for Disease Control and Prevention (CDC) Recommended Child and Adolescent Immunization Schedule for ages 18 years or younger; 2025 U.S. Schedule and the American Academy of Pediatrics (AAP) Immunization 2026 Schedule for Hepaitis B vaccination:

  • ​Infants born to a HBsAg positive mothers (or status unknown If other evidence suggestive of maternal hepatitis B infection exists [e.g., presence of HBV DNA, HBeAg-positive, or mother known to have chronic hepatitis B infection]) at age 9-12 months OR 1-2 months after final dose if the hepatitis B vaccine series was delayed. Testing is not recommended before age 9 months​

​​Revisions From 00.06.02ay:​
04/01/2026

This version of the policy will become effective 04/01/2026

 

The following updates have been made:


Attachment A

Routine Vaccines

As previously communicated in a Newsflash article (Coverage of Meningococcal Groups A, B, C, W, and Y Vaccine (PenmEnvy) for Commercial Members (Retroactively Effective 06/25/2025), the following CPT code was added: 90624


The following policy statement for Routine Vaccines was revised to include vaccine recommendations supported by professional society guidelines (i.e., American Academy of Pediatrics (​AAP), American Academy of Family Physicians (AAFP), ​American College of Obstetricians and Gynecologists (ACOG)​, American College of Physicians (ACP)​):​


In accordance with the Advisory Committee on Immunization Practices (ACIP), as well as those supported by professional society guidelines (i.e., American Academy of Pediatrics (​AAP), American Academy of Family Physicians (AAFP), ​American College of Obstetricians and Gynecologists (ACOG), American College of Physicians (ACP))​, routine immunization recommendations, routine vaccines, and their administration are covered as a preventive service for all adults.​
 

Attachment B

INTIMATE PARTNER AND DOMESTIC VIOLENCE SCREENING AND COUNSELING

The following statement was revised to include individuals ​who are pregnant and postpartum:

Intimate partner and domestic violence screening is covered as a preventive service at least annually for adolescent and adult females including those who are pregnant and postpartum. When recommended by the provider, intimate partner and domestic violence counseling is covered as a preventive service for adolescent and adult females including those who are pregnant and postpartum. Intervention services include, but are not limited to, counseling, education, harm reduction strategies, and appropriate supportive services.

 

SYPHILIS SCREENING

The following criterion was revised to include all pregnant individuals as early as the first prenatal visit.

Syphilis screening is covered as a preventive service when any of the following criteria are met:

  • All pregnant individuals as early as the first prenatal visit.
  • For high-risk pregnant individuals, repeat testing may be required in the third trimester and at delivery.
  • Individuals at increased risk for syphilis infection.

Risk factors for increased risk include, but not limited to :

    • Individuals who are HIV positive
    • Individuals with a history of incarceration
    • Individuals with a history of commercial sex work or military service
    • Individuals who use illicit drugs 
    • Individuals who are diagnosed with another sexually transmitted infection​

HUMAN PAPILLOMAVIRUS (HPV) SCREENING
The following statement was revised to indicate HPV screening is in accordance with the USPSTF recommendation for cervical cancer screening:

Human papillomavirus (HPV) screening is covered as a preventive service for all females 30 years and older every five years in accordance with the USPSTF recommendation for cervical cancer screening.

 

ATTACHMENT C

Routine Vaccines

As previously communicated in a Newsflash article (Coverage of Meningococcal Groups A, B, C, W, and Y Vaccine (PenmEnvy) for Commercial Members (Retroactively Effective 06/25/2025), the following CPT code was added: 90624 ​


The following policy statement for Routine Vaccines was revised to include vaccine recommendations supported by professional society guidelines (i.e., American Academy of Pediatrics (​AAP), American Academy of Family Physicians (AAFP), ​American College of Obstetricians and Gynecologists (ACOG)​, American College of Physicians (ACP)​):​


In accordance with the Advisory Committee on Immunization Practices (ACIP), as well as those supported by professional society guidelines (i.e., American Academy of Pediatrics (​AAP), American Academy of Family Physicians (AAFP), ​American College of Obstetricians and Gynecologists (ACOG), American College of Physicians (ACP))​, routine immunization recommendations, routine vaccines, and their administration are covered as a preventive service for all children.​


Revisions From 00.06.02ax:​
01/01/2026

This version of the policy will become effective 01/01/2026.


The following updates have been made:


Attachment A

Routine Vaccines

As previously communicated in a Newsflash article (Preventive Coverage of MNEXSPIKE (Covid-19 Vaccine, mRNA)) for Commercial Members retroactively effective July 1, 2025, the following CPT code was added: 91323


​Attachment B​


Breast Cancer Screening (Mammography)

The criteria were updated to include additional imagining, pathology evaluation and tissue biopsy as part of the preventive screening process. 

The following CPT codes have been added:

  • 76641, 76642, 77046, 77047, 77048, 77049, 77061, 77062, 77065, 77066, 19081, 19082, 19083, 19084, 19085, 19086, 19100, 19101, 88305, 88307, G0279


The following policy criteria has been added:


Patient navigation services for breast and cervical cancer screening were added to the policy as a new recommendation


The following HCPCS codes have been added:

  • G0023, G0024, G0140, G0146, Z12.4, Z12.39​

​

Intimate partner and domestic violence screening and counseling was added as a separate a separate recommendation. ​


The following CPT codes have been added:

  • 99401, 99402, 99403, 99404​​


Reproductive Education and Counseling, Contraception, and Sterilization

The following CPT codes (58565, 58600, 58605, 58611, 58615, 58661, 58670, AND 58671) have changed from always preventive to preventive when reported with the following ICD-10 codes:

Z30.011, Z30.012, Z30.013, Z30.014, Z30.015, Z30.016, Z30.017, Z30.018, Z30.019, Z30.02, Z30.09, Z30.2, Z30.40, Z30.41, Z30.42, Z30.430, Z30.431, Z30.432, Z30.433, Z30.44, Z30.45, Z30.46, Z30.49, Z30.8, Z30.9​


​Attachment C

Routine Vaccines

  • ​As previously communicated in a Newsflash article (Preventive Coverage of MNEXSPIKE (Covid-19 Vaccine, mRNA)​ for Commercial Members retroactively effective July 1, 2025,  the following CPT code was added: 91323
  • As previously communicated in a Newsflash article (Preventive Coverage of Clesrovimab (Enflonsia)) retroactively effective August 4, 2025, the following CPT code was added: 90382​​​

__________________________________________________________
In addition, this policy has been identified for the CPT and HCPCS code update, effective 01/01/2026:

Attachment A

Routine Vaccines​​

The following CPT code narrative has been revised: 90480

The following CPT code has been added: 90481


PREDIABETES AND TYPE 2 DIABETES MELLITUS SCREENING AND PREVENTIVE INTERVENTIONS

The following HCPCS code has been added: 

G9871 Behavioral counseling for diabetes prevention, online, 60 minutes


Services performed in connection with a preventive colorectal cancer screening procedure

The following HCPCS code has been added:

J2711 Injection, neostigmine methylsulfate 0.1 mg and glycopyrrolate 0.02 mg​


Attachment B

REPRODUCTIVE EDUCATION AND COUNSELING, CONTRACEPTION, AND STERILIZATION

The following HCPCS code has been added:

J7299 Intrauterine copper contraceptive (miudella)


Attachment C

Routine Vaccines ​

The following CPT code narrative has been revised: 90480

The following CPT code has been added: 90481​​

​

Revisions from 00.06.02aw:

10/01/2025

Inclusion of a policy in a Code Update memo does not imply that a full review of the policy was completed at this time.

This policy has been identified for the HCPCS and ICD-10 CM code update, effective 10/01/2025.

ATTACHMENT A
The following HCPCS code has been added to Attachment A of this policy (Services performed in connection with a preventive colorectal cancer screening procedure​): 
J0525
​

The Following HCPCS has been termed from Attachment A of this policy (Services performed in connection with a preventive colorectal cancer screening procedure​): 

S0074


ATTACHMENT B

The following HCPCS code has been added to attachment B of this policy (Breastfeeding Support/Counseling and Supplies​)​: 

A4288​


​The following HCPCS code has been revised in attachment B of this policy (Contraception​):

Changed From: J7300 Intrauterine copper contraceptive

Changed To: J7300 Intrauterine copper contraceptive (paragard)​


The following ICD-10 codes have been added to attachment B of this policy:

(Counseling Interventions to Prevent Perinatal Depression)

Z59.861 Financial insecurity, difficulty paying for utilities

Z59.868 Other specified financial insecurity

Z59.869 Financial insecurity, unspecified


The following ICD-10 codes have been added to attachment B of this policy:

(BRCA-related Cancer Risk Assessment, Genetic Counseling, and BRCA Mutation Testing)​

Z85.4A Personal history of malignant neoplasm of fallopian tube(s)​

Z86.00A Personal history of in-situ neoplasm of the fallopian tube(s)​


Revisions From 00.06.02av:​
07/01/2025

This version of the policy will become effective 7/01/2025.

The following updates have been made:

Attachment A

The policy criteria was updated to the following:

EXERCISE INTERVENTIONS FOR THE PREVENTION OF FALLS

Exercise interventions for community-dwelling (i.e. not living in a facility) adults 65 years of age or older who are at increased risk for falls are covered as a preventive service when the following criteria are met:

  • The exercise interventions include at least one of the following components:

    • Gait training

    • Balance training

    • Functional training

    • Strength and Resistance training

    • Flexibility

    • Endurance training

The following HCPCS codes have been added to Services performed in connection with a preventive colorectal cancer screening procedure: J0165, J2312, J2313, J3373

The following HCPCS codes have been termed (no longer valid code) from Services performed in connection with a preventive colorectal cancer screening procedure: J0171, J2310, J2311, J3370

The following CPT code narrative has been revised: 90620

As previously communicated in a Newsflash, the following CPT codes were added to the routine vaccines section of the coding table: 
90611, 90683, 90684
In addition, the following CPT codes were removed from the routine vaccines section of the coding table:
90380, 90381


​Attachment C​

The policy criterion was updated to the following:​

​HIGH BODY MASS BEHAVIORAL COUNSELING ​INTERVENTIONS

High body mass 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, behavioral counseling interventions are 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 high body mass counseling codes should be reported.​​

​The following CPT code narrative has been revised: 90620​

As previously communicated in a Newsflash, the following CPT codes were added to the routine vaccines section of the coding table​: 90611, 96380, 96381, 90683, 90684​


Revisions From 00.06.02au:​
04/01/2025

Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.
 

This policy has been identified for the HCPCS code update, effective 04/01/2025. 

Attachment A

  • Retroactively effective to​​ 06/27/2024, ​the following HCPCS code has been added to Hepatitis C virus Screening: G0567
  • The following HCPCS code has been added to Services performed in connection with a preventive colorectal cancer screening procedure: J1308​
  • The following HCPCS codes have been termed (no longer valid code) from Services performed in connection with a preventive colorectal cancer screening procedure: J1810, S0028

Attachment B

 

  • ​​The following HCPCS codes have been termed (no longer valid code) from Associated Services for Contraceptive:   J1094, J1810​


Revisions From 00.06.02at:​
01/01/2025

Attachment A

Colorectal Cancer Screening

  • The criteria for stool DNA testing alone or combined with FIT has been updated from every 3 years to every 1 to 3 years 
Depression Screening 
  • The following diagnosis codes were removed from this section : R45.851, T14.91XA, T14.91XD, T14.91XS, Z91.51
  • The following diagnosis code was added to this section: Z13.39​

Work-up and Follow-up Services for Pre-exposure Prophylaxis for the Prevention of HIV
  • ​Triglyceride and cholesterol level and weight checks were added for initiation and monitoring for emtricitabine with tenofovir alafenamide fumarate 

Pre-exposure prophylaxis for the prevention of HIV Infection

  • Emtricitabine (200 mg) with tenofovir alafenamide fumarate (25 mg) was added as a preventive drug.​

Routine Vaccines

  • The following CPT codes have been termed (no longer valid code) from this policy: 90630, 90654 ​

  • The following CPT narrative has been revised in this policy: 90661
Attachment B

Intimate partner violence was updated to intimate partner and domestic violence screening. 


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

  • The following CPT codes have been added from this policy:  96041
  • ​The following CPT codes have been termed (no longer valid code) from this policy:​96040 ​

D​epression Screening 
  • The following diagnosis codes were removed from this section : R45.851, T14.91XA, T14.91XD, T14.91XS, Z91.51
  • The following diagnosis code was added to this section: Z13.39​


Attachment C
Obesity Screening 
  • The title was updated to High Body Mass Screening 
Depression Screening 
  • The following diagnosis codes were removed from this section : R45.851, T14.91XA, T14.91XD, T14.91XS, Z91.51
  • The following diagnosis code was added to this section: Z13.39​​
Obesity Screening and Behavioral Counseling 
  • ​The title was updated to HIgh Body Mass Counseling.

Routine Vaccines

  • The following CPT codes have been termed (no longer valid code) from this policy: ​90630, 90654 ​

  • The following CPT narrative has been revised in this policy: 90661

Revisions From 00.06.02as:​
10/01/2024

Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.
 

This policy has been identified for the ICD-10 code update, effective 10/01/2024.

 

The following ICD-10 CM  codes have been added to this policy: 

Attachment B - Z59.71, Z59.72, 

Attachment C - Z68.55, Z68.56 

 

The following HCPCS  codes have been added to this policy: 

Attachment A - J1171

Attachment A and B - J2002, J2003, J2004 

 

The following ICD-10 CM code has been termed (no longer valid code) from this policy:

 Attachment B - Z59.7 

 

The following HCPCS  codes have been termed (no longer valid code) from this policy:

Attachment A - J1170

Attachment B - J2001

 

The following ICD-10 narrative has been revised in this policy (Attachment C): Z68.54 ​


Revisions From 00.06.02ar:​
07/01/2024

Attachment A

  • Anxiety screening was added as a new recommendation.
  • In the Work-up and follow-up Services for Pre-exposure Prophylaxis for the Prevention of HIV section, the criteria was updated to distinguish the follow-up services for oral medication and injectable medication.  Diagnosis code Z29.81 was added to this section.  Procedure codes 36415, 36416, and 99000 was added to this section. 
  • In the pre-exposure prophylaxis for the prevention of HIV infection section, injectable cabotegravir was added as a preventive service. Procedure code J0739 was added to this section. Diagnosis code Z29.81 was added to this section.
  • In the prescription bowel preparation medication section, PEG-prep and PEG 3350 powder for solution were added
  • In routine vaccines section, procedure code 91304 was added. 

Attachment B

  • In prenatal Care Visits section, preeclampsia screening was renamed screening for hypertensive disorders. 
  • The chlamydia screening and gonorrhea screening have been combined to one recommendation. Procedure codes 36415 and 36416 were added to this section. 
  • In the Human Papillomavirus (HPV) screening section was updated to add procdeure codes 36415 and 36416. 
  • In counseling interventions to prevent perinatal depression section, diagnosis codes F41.0, F41.1, F41.3, F41.8, F41.9 were added.
  • In the well-woman visit section, the following procedure code was added to this section: 99459
  • In breast cancer screening, the frequency was added to annually.​
     

Attachment C

  • The chlamydia screening and gonorrhea screening have been combined to one recommendation. ​Procedure codes 36415 and 36416 were added to this section. ​
  • ​In the vision screening, the following diagnosis codes were added to this section: Z00.00, Z00.01​

-------------------------------------------------------------------------------------------------------------------

The following HCPCS code has been added to this policy:


Attachment A under associated services for colorectal cancer screening and associated services for contraception
J1597


The following HCPCS  codes have been termed (no longer valid code) from this policy:

Under Associated Services for Colorectal Cancer Screening (Attachment A) and Follow-up and Management of Contraceptive Services (attachment D) 
J2780 

Under Associated Services for Colorectal Cancer Screening (Attachment A)
S0164​


Revisions From 00.06.02aq:​
04/01/2024Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.
 
This policy has been identified for the HCPCS code update, effective 04/01/2024.
The following HCPCS code has been added to the Reproductive Education and Counseling, Contraception, and Sterilization section on attachment B of this policy to be reported with the diagnosis code Z30.8:  A9293 ​


Revisions From 00.06.02ap:

01/02/2024

 Inclusion of a policy in a Code Update memo does not imply that a full review of the policy was completed at this time


This policy has been identified for the CPT and HCPCS  code update, effective 01/02/2024.


The following HCPCS codes have been added to Work-up and Follow-up Services for Pre-Exposure Prophylaxis for the Prevention of HIV  section on attachment A of this policy:  G0011, G0013


The following HCPCS codes have been added to Prediabetes and Type 2 Diabetes Mellitus Screening and Preventive Interventions  section on attachment A of this policy: G9886, G9887, G9888


The following CPT code has been added to Routine Vaccines on attachment A and C of this policy: 90623


The following HCPCS code has been added to Breastfeeding Support/Counseling and Supplies section  on attachment B of this policy: A4287


The following CPT codes have been termed (no longer valid codes) and removed from Routine Vaccines on attachment A and C this policy: 0001A, 0002A, 0003A, 0004A, 0011A, 0012A, 0013A, 0031A, 0034A, 0041A, 0042A, 0044A, 0051A, 0052A, 0054A, 0064A, 0071A, 0072A, 0073A, 0074A, 0081A, 0082A, 0083A, 0091A, 0092A, 0093A, 0094A, 0111A, 0112A, 0113A, 0124A, 0134A, 0144A, 0154A, 0164A, 0173A, 0174A


The following HCPCS code has been termed (no longer valid codes) and removed from Breastfeeding Support/Counseling and Supplies section on attachment B this policy: K1005


The following CPT narratives have been revised in this policy: 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215


Revisions From 00.06.02ao:
01/01/2024

 Attachment A

  • Colorectal Cancer Screening
    • The age criteria for colorectal cancer screening was updated to include a maximum age.
  • Depression screening
    • The title was updated to be depression and suicide risk screening
    • The following diagnosis codes were added: R45.851, T14.91XA, T14.91XD, T14.91XS, Z91.51
  • Latent Tuberculosis Infection Screening
    • The criteria was updated to add chest x-ray.
    • The following codes were added:  86480, 86481, 71045, Z20.1
  • Lipid Disorder Screening
    • The frequency limits were updated.
  • Behavioral Interventions for Weight Loss
    • The title was changed to Behavioral interventions for weight loss to prevent obesity-related morbidity and mortality
    • The policy criteria was updated to address the components of the interventions. 
    • The following CPT code was added: G0473
  • Nutritional counseling
    • As previously communicated through a newsflash, the criteria for nutritional counseling was updated.
       
  • Routine Vaccines
    • As previously communicated through a news article, the following codes were added: 90380, 90381, 90678, 90679

Attachment B

  • Depression Screening
    • The title was updated to Depression and Suicide Risk Screening
    • The following diagnosis codes were added: R45.851, T14.91XA, T14.91XD, T14.91XS, Z91.51

Attachment C

  • Prebirth Visits
    • The title was changed to pediatric prenatal visits
  • Depression and Suicide Risk Screening
    • The following diagnosis codes were added: T14.91XA, T14.91XD, T14.91XS, Z91.51
  • Tuberculosis Testing
    • The following diagnosis code was added:  86480, 86481,​ Z20.1
  • Nutritional Counseling for Weight Management
    • ​This recommendation was added to this attachment
  • Obesity Screening and Behavioral Counseling
    • The following code was added: G0473
  • R​outine Vaccines
    • As previously communicated through a news article, the following codes were added: 90380, 90381, 90678, 90679

Revisions From 00.06.02an:

10/01/2023​

Inclusion of a policy in a Code Update memo does not imply that a full review of the policy was completed at this time.


This policy has been identified for the ICD-10 CM code update, effective 10/01/2023.

The following ICD-10 CM codes have been added to Osteoporosis Screening section on attachment B of this policy:


M80.0B1A, M80.0B1D, M80.0B1G, M80.0B1K, M80.0B1P, M80.0B1S, M80.0B2A, M80.0B2D, M80.0B2G, M80.0B2K, M80.0B2P, M80.0B2S, M80.0B9A, M80.0B9D, M80.0B9G, M80.0B9K, M80.0B9P, M80.0B9S


As previously communicated through the COVID-19 vaccine newsflash effective 09/11/2023:


  • The following codes were removed from the policy: 0001A, 0002A, 0003A, 0004A, 0011A, 0012A, 0013A, 0031A, 0034A, 0051A, 0052A, 0053A, 0054A, 0064A, 0071A, 0072A, 0073A, 0074A, 0081A, 0082A, 0083A, 0091A, 0092A, 0093A, 0094A, 0111A, 0112A, 0113A, 0121A, 0124A, 0134A, 0141A, 0142A, 0144A, 0151A, 0154A, 0164A, 0171A, 0172A, 0173A, 0174A​
  • The following codes were added to the policy: 90480, 91318, 91319, 91320, 91321, 91322

Revisions From 00.06.02am:

07/01/2023

As previously communicated through a news article, the administration of COVID vaccine codes were added to the routine vaccines section of attachments A and C: 0001A, 0002A, 0003A, 0004A, 0011A, 0012A, 0013A, 0031A, 0034A, 0041A, 0042A, 0044A, 0051A, 0052A, 0053A, 0054A, 0064A, 0071A, 0072A, 0073A, 0074A, 0081A, 0082A, 0083A, 0091A, 0092A, 0093A, 0094A, 0111A, 0112A, 0113A, 0124A, 0134A, 0144A, 0154A, 0164A, 0173A, 0174A


​On attachment A, procedure code Z20.6 was added to the work-up and follow-up services for pre-exposure prophylaxis for the prevention of HIV. 

On attachment A, in the associated services section of the colorectal cancer screening section: 

  • The following codes have been added : J0457; J0665; J0736; J1836
  • The following codes have been termed : S0020; S0030; S0073; S0077

​On attachment B, in the associated services of the contraceptive section: 

  • ​The following code has been added: J1836
  • The following code have been termed: S0020​
On attachment C, anxiety screening was added as a new service.​


Revisions From 00.06.02al:
04/01/2023

Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.
​
This policy has been identified for the ICD-10 CM code update, effective 04/01/2023.


The following ICD-10 CM codes have been added to Counseling Interventions to Prevent Perinatal Depression section on Attachment B of this policy:


Z59.10 Inadequate housing, unspecified

Z59.11 Inadequate housing environmental temperature

Z59.12 Inadequate housing utilities

Z59.19 Other inadequate housing

Z91.414 Personal history of adult intimate partner abuse

Z62.815 Personal history of intimate partner abuse in childhood


Revisions From 00.06.02ak:
01/01/2023

Attachment A

Abnormal Blood Glucose/Prediabetes and Type 2 Diabetes Mellitus Screening and Preventive Interventions

  • The title and criteria was updated to Prediabetes and Type 2 Diabetes Mellitus Screening and Preventive Interventions

​Colorectal Cancer Screening

  • As previously communicated, the preventive coverage criteria for follow-up colonoscopy after a positive non-invasive stool-based screening test was added 
  •  The following HCPCS codes have been added to this policy: J2311, J2401, J2402
  • The following CPT and HCPCS code has been termed to this policy: J2400​

 ​Low dose Aspirin

  • This was removed as a recommendation.

Routine Vaccines

  • The following code was added: 90587


Attachment B

The following were added as new recommendations:

  • Behavioral Counseling for Sexually Transmitted Infections
  • Counseling for the Prevention of Obesity to the services incldued as part of the comprehensive preventive exam or well-visit​
  • Postpartum care visits

​Breast Cancer Chemoprevention

  • The policy criteria were updated to include raloxifene and aromatase inhibitors

Reproductive Education and Counseling, Contraception, and Sterilization

  • The policy criteria were updated add non-hormonal contraceptive gel as a contraceptive method
  • The policy criteria were updated to address all condoms. 
  • The following codes were added: A4267, J3490, 58661 
  • The associated services for contraceptive surgery was updated to associated services for contraceptive to address the coverage of associated services for all contraceptives.    

Breastfeeding Support/Counseling and Supplies

  • The policy criterion was updated to include breast milk storage supplies as preventive.

Attachment C

​Autism and Developmental Screening

  • Procedure code Z13.41 was added​.

Depression Screening

  • The title and policy criteria were updated to include suicide risk screening.
  • The following diagnosis codes were added: R45.851, Z91.51

Hepatitis B Virus Screening

  • The following diagnosis codes were added: Z00.110, Z00.111

Psychosocial/Behavioral Assessment

  • The title was changed to Behavioral/Social/Emotional Screening 
  • The following codes were added to this section: 96127, Z13.39

Risk Assessment of Sudden Cardiac Arrest and Sudden Cardiac Death

  • This was added as a new recommendation under services included as part of the comprehensive preventive exam or newborn care

Routine Vaccines

  • The following code was added to this section: 90587

Revisions From 00.06.02aj:
10/01/2022Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.

This policy has been identified for the HCPCS and ICD-10 CM code update, effective 10/01/2022.

The following ICD-10 CM codes have been termed from this policy:

Behavorial Counseling for STI (Attachment A, B, C)

​Work-Up and Follow-Up Services for Pre-Exposure Prophylasis for the Prevention of HIV (Attachment B) 

Chlamydia Screening (Attachment B, C)​

Gonorrhea​ Screening (Attachment B, C)

​B37.3  


The following HCPCS and ICD-10 CM codes have been added to this policy:

Behavorial Counseling for STI (Attachment A, B, C)

​Work-Up and Follow-Up Services for Pre-Exposure Prophylasis for the Prevention of HIV (Attachment B) 

Chlamydia Screening (Attachment B, C)​

Gonorrhea​ Screening (Attachment B, C)​

B37.31   B37.32

Breastfeeding Support/Counseling and Supplies (Attachment B)

K​1005 


Revisions From 00.06.02ai:
07/01/2022

Attachment A:

 

  • The Abnormal Blood Glucose and Type 2 Diabettes Mellitus Screening the Intensive Behavioral Counseling Interventions was changed to Abnormal Blood Glucose/Prediabetes and Type 2 Diabetes Mellitus Screening and Preventive Interventions. 
    • The screening age limits was changed from 40-70 years to 35-70 years every three years. 
    • The frequency of sessions was changed from 24 sessions a year to 32 sessions a year.
    • A definition of prediabetes was added. ​
  • Immunizations 
    • The name of this section has been changed to Routine Vaccines.
    • ​The following codes were added to this section: 90671, 90677
​​Attachment B
  • ​Chlamydia Screening
    • ​​History of incarceration was added as a risk factor for increased risk for chlamydia
    • The following diagnosis code was added to this section: Z65.1
  • ​​Gonorrhea Screening 
    • ​​History of incarceration was added as a risk factor for increased risk for chlamydia
    • The following diagnosis code was added to this section: Z65.1​
  • ​​Reproductive Education and Counseling, Contraception, and Sterilization​
    • As previously communicated, FDA-approved contraceptive mobile applications was added as a contraceptive method. ​
​​​Attachment C
  • Immunizations 
    • The name of this section has been changed to Routine Vaccines.
    • ​The following codes were added to this section: 90671, 90677​​

Revisions From 00.06.02ah:
01/01/2022This version of the policy will become effective 01/01/2022. 

Attachment A
  • Colorectal Cancer Screening 
    • As previously communicated in the newsflash, colorectal cancer screening policy criteria was updated to lower the starting age for screening to 45 years of age.
  • ​Hepatitis B Virus Screening
    • The policy criteria for high risk was updated. ​
  • ​​Lung Cancer Screening
    • ​​The policy criteria was updated to lower the initial age for screening to start at 50 years and lower the criteria for the pack-year smoking history. ​​
  • ​​Behavioral Counseling to Promote a Healthful Diet and Physical Activities for Cardiovascular Diesase Prevention
    • The policy criteria was updated to address the following: 
      • The cardiovascular disease risk factors were updated 
      • Overweight or obese was removed as a requirement for the behavioral counseling. 
      • Frequency information was added. 
    • ​​Behavioral Counseling for Prevention of Sexually Transmitted Infections
      • ​The following diagnosis codes were added to the policy:  F11.10, F11.120, F11.121, F11.122, F11.129, F11.13, F11.14, F11.150, F11.151, F11.159, F11.181, F11.182, F11.188, F11.19, F11.20, F11.220, F11.221, F11.222, F11.229, F11.23, F11.24, F11.250, F11.251, F11.259, F11.281, F11.282, F11.288, F11.29, F11.90, F11.920, F11.921, F11.922, F11.929, F11.93, F11.94, F11.950, F11.951, F11.959, F11.981, F11.982, F11.988, F11.99, F13.10, F13.120, F13.121, F13.129, F13.130, F13.131, F13.132, F13.139, F13.14, F13.150, F13.151, F13.159, F13.180, F13.181, F13.182, F13.188, F13.19, F13.20, F13.220, F13.221, F13.229, F13.230, F13.231, F13.232, F13.239, F13.24, F13.250, F13.251, F13.259, F13.26, F13.27, F13.280, F13.281, F13.282, F13.288, F13.29, F13.90, F13.920, F13.921, F13.929, F13.930, F13.931, F13.932, F13.939, F13.94, F13.950, F13.951, F13.959, F13.96, F13.97, F13.980, F13.981, F13.982, F13.988, F13.99, F14.10, F14.120, F14.121, F14.122, F14.129, F14.13, F14.14, F14.150, F14.151, F14.159, F14.180, F14.181, F14.182, F14.188, F14.19, F14.20, F14.220, F14.221, F14.222, F14.229, F14.23, F14.24, F14.250, F14.251, F14.259, F14.280, F14.281, F14.282, F14.288, F14.29, F14.90, F14.920, F14.921, F14.922, F14.929, F14.93, F14.94, F14.950, F14.951, F14.959, F14.980, F14.981, F14.982, F14.988, F14.99, F15.10, F15.120, F15.121, F15.122, F15.129, F15.13, F15.14, F15.150, F15.151, F15.159, F15.180, F15.181, F15.182, F15.188, F15.19, F15.20, F15.220, F15.221, F15.222, F15.229, F15.23, F15.24, F15.250, F15.251, F15.259, F15.280, F15.281, F15.282, F15.288, F15.29, F15.90, F15.920, F15.921, F15.922, F15.929, F15.93, F15.94, F15.950, F15.951, F15.959, F15.980, F15.981, F15.982, F15.988, F15.99, F19.10, F19.120, F19.121, F19.122, F19.129, F19.130, F19.131, F19.132, F19.139, F19.14, F19.150, F19.151, F19.159, F19.16, F19.17, F19.180, F19.181, F19.182, F19.188, F19.19
    • Work-up and Follow-up Services for Pre-exposure Prophylaxis for the Prevention of HIV
      • ​As previously communicated, this was added as a new section. 
    • ​Immunizations
      • The following procedure codes were removed from the policy: 90644, 90733, 90736​
    Attachment B 
    • Prenatal Visits 
      • The policy criteria was updated to add​ behavioral counseling interventions for healthy weight and weight gain in pregnancy as part of the prenatal visit. 
    • ​Hepatitis B Virus Screening
      • The policy criteria for high risk was updated. 
    Attachment C
    • Hepatitis B Virus Screening 
      • The policy criteria for high risk was updated. 
    • ​​​Immunizations 
      • ​​The following procedure codes were removed from the policy: 90644, 90733, 90736
    Note: On 12/22/2021, t​he policy ​in Notification has been updated to revise CPT code narratives for the following codes:  99211, 11981​

    Revisions From 00.06.02ag:
    10/01/2021Inclusion of a policy in a Code Update memo does not imply that a full review of
    the policy was completed at this time.

    This policy has been identified for the HCPCS and ICD-10 CM code update, effective 10/01/2021.

    The following HCPCS and ICD-10 CM codes have been termed from this policy:

    Attachment B - Counseling Interventions to Prevent Perinatal Depression​ 

    ​Z91.5 Personal history of self-harm

    Attachment B - Reproductive Education and Counseling, Contraception, and Sterilization​

     J7303 Contraceptive supply, hormone containing vaginal ring, each

    The following HCPCS and ICD-10 CM codes have been added to this policy:

    Attachment B - Counseling Interventions to Prevent Perinatal Depression​ 

    Z91.51 Personal history of suicidal behavior

    Z91.52 Personal history of nonsuicidal self-harm

    Attachment B - Reproductive Education and Counseling, Contraception, and Sterilization​

    J7294 Segesterone acetate and ethinyl estradiol 0.15mg, 0.013mg per 24 hours; yearly vaginal system, each

    J7295 Ethinyl estradiol and etonogestrel 0.015mg, 0.12mg per 24 hours; monthly vaginal ring, each


    The following  ICD-10 CM narrative has been revised in this policy:

    Attachment A and C - Hepatitis B Screening

    Z92.25

    FROM: Personal history of immunosupression therapy

    TO: Personal history of immunosuppression therapy​

    ​
    ​    Revisions From 00.06.02af:
    07/01/2021

    ​ Attachment A:

    Behavioral Counseling for Prevention of Sexually Transmitted Infections 

    • The language criteria was updated to include a list of risk factors. 
    • The following codes were added to the recommendation: A50.01, A50.02, A50.03, A50.04, A50.05, A50.06, A50.07, A50.08, A50.09, A50.1, A50.2, A50.30, A50.31, A50.32, A50.39, A50.40, A50.41, A50.42, A50.43, A50.44, A50.45, A50.49, A50.51, A50.52, A50.53, A50.54, ​A50.55, A50.56, A50.57, A50.59, A50.6, A50.7, A50.9, A51.1, A51.2, A51.31, A51.32, A51.39, A51.41, A51.42, A51.43, A51.44, A51.45, A51.46, A51.49, A51.5, A51.9, A52.00, A52.01, A52.02, A52.03, A52.04, A52.05, A52.06, A52.09, A52.10, A52.11, A52.12, A52.13, A52.14, A52.15, A52.16, A52.17, A52.19, A52.2, A52.3, A52.71, A52.72, A52.73, A52.74, A52.75, A52.76, A52.77, A52.78, A52.79, A52.8, A52.9, A53.0, A53.9, A54.00, A54.01, A54.02, A54.03, A54.09, A54.1, A54.21, A54.22, A54.23, A54.24, A54.29, A54.30, A54.31, A54.32, A54.33, A54.39, A54.40A54.41, A54.42, A54.43, A54.49, A54.5, A54.6, A55, A56.00, A56.01, A56.02, A56.09, A56.11, A56.19, A56.2, A56.3, A56.4, A56.8, A59.00, A59.01, A59.02, A59.03, A59.09, A59.8, A59.9, A60.00, A60.01, A60.02, A60.03, A60.04, A60.09, A60.1, A60.9, A63.0, A63.8, A65, A70, A74.0, A74.81, A74.89, A74.9, B00.0, B00.1, B00.2, B00.3, B00.4, B00.50, B00.51, B00.52, B00.53, B00.59, B20, B37.3, B97.7, F52.8, F64.0, F64.1,  F64.2, F64.8, F64.9, N34.0, N34.1, N34.2, N34.3, N72, N73.0, N73.1, N73.2, N73.3, N73.4, N73.5, N73.6, N73.8, N73.9, P35.2, R85.81, R85.82, R87.810, R87.811, R87.820, R87.821, Z11.3, Z20.2, Z21, Z65.1, Z72.51, Z72.52, Z72.53, Z72.89, Z77.21, Z86.19, Z87.890, Z91.42​​
    ​Attachment C

    Behavioral Counseling for Prevention of Sexually Transmitted Infections 

    • The language criteria was updated to indicate all sexually active adolescents are considered eligible for this service.

    Revisions From 00.06.02ae:
    01/01/2021

    Attachment A:

    • Hepatitis C Virus Screening
      • The policy criteria was updated to align with the updated US Preventive Services Task Force recommendation.
      • The following diagnosis codes have been removed:

        F11.10, F11.11, F11.120, F11.121, F11.122, F11.129, F11.14, F11.150, F11.151, F11.159, F11.181, F11.182, F11.188, F11.19, F11.20, F11.21, F11.220, F11.221, F11.222, F11.229, F11.23, F11.24, F11.250, F11.251, F11.259, F11.281, F11.282, F11.288, F11.29, F11.90, F11.920, F11.921, F11.922, F11.929, F11.93, F11.94, F11.950, F11.951, F11.959, F11.981, F11.982, F11.988, F11.99, F13.10, F13.11, F13.120, F13.121, F13.129, F13.14, F13.150, F13.151, F13.159, F13.180, F13.181, F13.182, F13.188, F13.19, F13.20, F13.21, F13.220, F13.221, F13.229, F13.230, F13.231, F13.232, F13.239, F13.24, F13.250, F13.251, F13.259, F13.26, F13.27, F13.280, F13.281, F13.282, F13.288, F13.29, F13.90, F13.920, F13.921, F13.929, F13.930, F13.931, F13.932, F13.939, F13.94, F13.950, F13.951, F13.959, F13.96, F13.97, F13.980, F13.981, F13.982, F13.988, F13.99, F14.10, F14.11, F14.120, F14.121, F14.122, F14.129, F14.14, F14.150, F14.151, F14.159, F14.180, F14.181, F14.182, F14.188, F14.19, F14.20, F14.21, F14.220, F14.221, F14.222, F14.229, F14.23, F14.24, F14.250, F14.251, F14.259, F14.280, F14.281, F14.282, F14.288, F14.29, F14.90, F14.920, F14.921, F14.922, F14.929, F14.94, F14.950, F14.951, F14.959, F14.980, F14.981, F14.982, F14.988, F14.99, F15.10, F15.11, F15.120, F15.121, F15.122, F15.129, F15.14, F15.150, F15.151, F15.159, F15.180, F15.181, F15.182, F15.188, F15.19, F15.20, F15.21, F15.220, F15.221, F15.222, F15.229, F15.23, F15.24, F15.250, F15.251, F15.259, F15.280, F15.281, F15.282, F15.288, F15.29, F15.90, F15.920, F15.921, F15.922, F15.929, F15.93, F15.94, F15.950, F15.951, F15.959, F15.980, F15.981, F15.982, F15.988, F15.99, F16.10, F16.11, F16.120, F16.121, F16.122, F16.129, F16.14, F16.150, F16.151, F16.159, F16.180, F16.183, F16.188, F16.19, F16.20, F16.21, F16.220, F16.221, F16.229, F16.24, F16.250, F16.251, F16.259, F16.280, F16.283, F16.288, F16.29, F16.90, F16.920, F16.921, F16.929, F16.94, F16.950, F16.951, F16.959, F16.980, F16.983, F16.988, F16.99, F18.10, F18.11, F18.120, F18.121, F18.129, F18.14, F18.150, F18.151, F18.159, F18.17, F18.180, F18.188, F18.19, F18.20, F18.21, F18.220, F18.221, F18.229, F18.24, F18.250, F18.251, F18.259, F18.27, F18.280, F18.288, F18.29, F18.90, F18.920, F18.921, F18.929, F18.94, F18.950, F18.951, F18.959, F18.97, F18.980, F18.988, F18.99, F19.10, F19.11, F19.120, F19.121, F19.122, F19.129, F19.14, F19.150, F19.151, F19.159, F19.16, F19.17, F19.180, F19.181, F19.182, F19.188, F19.19, P00.2, W46.0XXA, W46.0XXD, W46.0XXS, W46.1XXA, W46.1XXD, W46.1XXS, Z00.00, Z00.01, Z11.3, Z11.59, Z20.5, Z65.1, Z72.51, Z72.52, Z72.53, Z77.21, Z86.59, Z99.2 
    • Unhealthy drug use screening was added as a new recommendation.
    • Immunizations
      • The following code was added to the policy: 90697
    • The following CPT code and HCPCS code were termed from the policy: 99201, G0297
      The following CPT code was added to the policy: 71271
    ​​Attachment B
    • Anxiety screening was added as a new recommendation.
    • Depression
      • The following codes were added to the policy: 96160 and 96161. 
    • Iron deficiency Anemia Screening was removed from this attachment.
    • HPV Screening
      • The policy criteria was updated to the following to update the interval between tests from three years to five years.
      • The following code was added to the policy: G0476
    • The following CPT code was termed from the policy: 99201

    Attachment C

    • Immunizations
      • The following code was added to the policy: 90697
    • The following CPT code was termed from the policy: 99201​

    Revisions From 00.06.02ad:
    10/01/2020

    Inclusion of a policy in a Code Update memo does not imply that a full review of
    the policy was completed at this time.

    This policy has been identified for the  HCPCS and ICD-10 code update, effective 10/01/2020.

    The following ICD-10 CM codes have been added to this policy:

    On attachment A, B, and C

    F11.13 Opioid abuse with withdrawal

    F13.130 Sedative, hypnotic or anxiolytic abuse with withdrawal, uncomplicated

    F13.131 Sedative, hypnotic or anxiolytic abuse with withdrawal delirium

    F13.132 Sedative, hypnotic or anxiolytic abuse with withdrawal with perceptual disturbance

    F13.139 Sedative, hypnotic or anxiolytic abuse with withdrawal, unspecified

    F14.13 Cocaine abuse, unspecified with withdrawal

    F14.93 Cocaine use, unspecified with withdrawal

    F15.13 Other stimulant abuse with withdrawal

    F19.130 Other psychoactive substance abuse with withdrawal, uncomplicated

    F19.131 Other psychoactive substance abuse with withdrawal delirium

    F19.132 Other psychoactive substance abuse with withdrawal with perceptual disturbance

    F19.139 Other psychoactive substance abuse with withdrawal, unspecified

    On attachment B

    M80.0AXA Age-related osteoporosis with current pathological fracture, other site, initial encounter for fracture

    M80.0AXD Age-related osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with routine healing

    M80.0AXG Age-related osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with delayed healing

    M80.0AXK Age-related osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with nonunion

    M80.0AXP Age-related osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with malunion

    M80.0AXS Age-related osteoporosis with current pathological fracture, other site, sequela

    M80.8AXA Other osteoporosis with current pathological fracture, other site, initial encounter for fracture

    M80.8AXD Other osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with routine healing

    M80.8AXG Other osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with delayed healing

    M80.8AXK Other osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with nonunion

    M80.8AXP Other osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with malunion

    M80.8AXS Other osteoporosis with current pathological fracture, other site, sequela


    The following HCPCS narrative has been revised in this policy:

    G2011 (Attachment A, B, and C)

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

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


    The following narrative change (as indicated in bold) was made to ICD-10 CM codes:

    Attachment A


    Z68.30 Body mass index [BMI]30.0-30.9, adult

    Z68.31 Body mass index [BMI] 31.0-31.9, adult

     

    Z68.32 Body mass index [BMI] 32.0-32.9, adult

    Z68.33 Body mass index [BMI] 33.0-33.9, adult

    Z68.34 Body mass index [BMI] 34.0-34.9, adult

    Z68.35 Body mass index [BMI] 35.0-35.9, adult

    Z68.36 Body mass index [BMI] 36.0-36.9, adult

    Z68.37 Body mass index [BMI] 37.0-37.9, adult

    Z68.38 Body mass index [BMI] 38.0-38.9, adult

    Z68.39 Body mass index [BMI] 39.0-39.9, adult

    Z68.41 Body mass index [BMI]40.0-44.9, adult

    Z68.42 Body mass index [BMI] 45.0-49.9, adult

    Z68.43 Body mass index [BMI] 50.0-59.9, adult

    Z68.44 Body mass index [BMI] 60.0-69.9, adult

    Z68.45 Body mass index [BMI] 70 or greater, adult​


    Revisions From 00.06.02ac:
    07/01/2020Attachment A
    • Colorectal Cancer Screening
      • As previously communicated in a Newsflash (effective 04/15/2020), the following codes (consultation codes) were removed from the associated services list: 99241, 99242, 99243
    • Pre-exposure prophylaxis for the prevention of HIV infection.
      • This is a new recommendation to the policy
    ​Attachment B
    • BRCA-related Cancer Risk Assessment, Genetic Counseling, and BRCA Mutation Testing
      • The policy criteria was updated to include ancestry associated with BRCA 1/2 gene mutations
    Attachment C
    • Fluoride Varnish Application
      • As previously communicated in a Newsflash (effective 05/01/2015), The policy criteria was updated to make the frequency every three months.
    ​​​​​__________________________________________________

    Note: the policy in Notification was updated 07/01/2020 to include the following changes:

    The following CPT codes have been added to this policy: 0172U 90619

    Revisions From 00.06.02ab:
    01/01/2020
      Attachment A
      • Hepatitis B Virus Screening
        • Applicable ICD-10 diagnosis codes have been added to the policy due to criteria changes.
      • Hepatitis C Virus Screening
        • Applicable ICD-10 diagnosis codes have been added to the policy due to criteria changes.
      • Syphilis Screening
        • The policy criteria were updated to include risk factors for increased risk.
        • Applicable ICD-10 diagnosis codes have been added to the policy due to criteria changes.
      • Immunizations
        • The following codes were removed from the policy: 90649, 90650

      Attachment B
      • Chlamydia Screening
        • The policy criteria were updated to include risk factors for increased risk.
        • Applicable ICD-10 diagnosis codes have been added to the policy due to criteria changes.
      • Gonorrhea Screening
        • The policy criteria were updated to include risk factors for increased risk.
        • Applicable ICD-10 diagnosis codes have been added to the policy due to criteria changes.
      • Syphilis Screening
        • The policy criteria were updated to include risk factors for increased risk.
        • Applicable ICD-10 diagnosis codes have been added to the policy due to criteria changes.
      • Hepatitis B Virus Screening
        • Applicable ICD-10 diagnosis codes have been added to the policy due to criteria changes.
      • Counseling interventions to prevent perinatal depression is a new recommendation to the policy.

      Attachment C
      • Chlamydia Screening
        • The policy criteria were updated to include risk factors for increased risk.
        • Applicable ICD-10 diagnosis codes have been added to the policy due to criteria changes.
      • Gonorrhea Screening
        • The policy criteria were updated to include risk factors for increased risk.
        • Applicable ICD-10 diagnosis codes have been added to the policy due to criteria changes.
      • Hepatitis B Virus Screening
        • Applicable ICD-10 diagnosis codes have been added to the policy due to criteria changes.
      • Syphilis Screening
        • The policy criteria were updated to include risk factors for increased risk.
        • Applicable ICD-10 diagnosis codes have been added to the policy due to criteria changes.
      • Immunizations
        • The following codes were removed from the policy: 90649, 90650
    ​​​​_________________________________________________________

    Note: On 01/22/2020, Attachments A and C of this policy were updated to incorporate coding changes effective 01/01/2020.
    • The following CPT codes have been added to Attachments A and C of this policy: 90694, 99473, 99474

    Revisions From 00.06.02aa:
    10/01/2019 This version of the policy will become effective 10/01/2019. The following ICD-10 code has been added to this policy: Z11.7.

    Revisions From 00.06.02z:
    07/01/2019 This version of the policy will become effective 07/01/2019.
      Attachment A
      • Alcohol use/misuse screening and behavioral counseling intervention
        • The title was changed to Unhealthy Alcohol Use Screening and Behavioral Counseling Interventions
      • Obesity screening and behavioral counseling
        • The title was changed to Behavioral Interventions for Weight Loss
        • Obesity Screening was added to Services Included as Part of the Comprehensive Preventive Exam
      • Counseling for the Prevention of Falls
        • The title was changed to Exercise Interventions for the Prevention of Falls
        • The following codes were removed from the recommendation: 99401, 99402, 99403, 99404
        • The following CPT codes were added to the recommendation: 97110, 97112, 97116, 97150, 97161, 97162, 97163, 97164, 97530
        • The following ICD-10 diagnosis codes were added to the recommendation: R26.0, R26.1, R26.2, R26.81, R26.89, R26.9, R29.6, Z91.81
        • The following modifier was added to the recommendation: 33
      • Nutritional Counseling
        • The policy criteria was updated to not limit to PA plans only.
      • Prescription Bowel Preparation Medication
        • The policy criteria was updated to add PEG3350 as a preventive drug.
      • Medications
        • The policy criteria for bowel preparation medication was updated to include specific drugs.
        • The policy criteria for tobacco cessation medication was updated to include specific drugs.
      • Immunizations
        • The following codes were added to the policy: 90654, 90660, Q2034
      Attachment B
      • Chlamydia
        • The following code was added to the policy: 99000
      • Gonorrhea
        • The following code was added to the policy: 99000
      • HIV Screening
        • The policy criteria was updated to address the frequency of testing.
      • Cervical Cancer Screening
        • Additional criteria was added to the recommendation.
      • Unhealthy Alcohol Use Screening and Behavioral Counseling Interventions
        • This is a new recommendation to this attachment.
        • The following codes were added for this recommendation: 99408,99409,G0442, G0443, G2011
      • Human Papillomavirus (HPV) Screening
        • The following code was added to the recommendation: 99000
      • Osteoporosis (Bone Mineral Density) Screening
        • The policy criteria was updated to lower the level of risk from high risk to increased risk.
      • Medications
        • The policy criteria for breast cancer chemoprevention was updated to include tamoxifen.
      Attachment C
      • Alcohol and Drug Use/Misuse Screening and Behavioral Counseling
        • The title was updated to Alcohol and Drug Use Screening and Behavioral Counseling Intervention
      • Chlamydia Screening
        • The following code was added to the policy: 99000
      • Hemoglobin/Hematocrit Testing
        • The title was changed to iron deficiency anemia screening.
      • Newborn Screening Panel
        • The policy criteria was updated to include spinal muscular atrophy
      • Visual Impairment Screening
        • The title was changed to Vision Screening
      • Fluoride
        • The age criteria was expanded to align with Bright Futures recommendations. The dosage was included in the policy criteria.
      • Immunizations
        • The following codes were added to the policy: 90654, 90660, Q2034

    Revisions From 00.06.02y:
    01/02/2019This version of the policy will become effective 01/02/2019.

    The following CPT codes have been termed from this policy:
    81211 81213 81214

    The following CPT codes have been added to this policy:
    81163 81164 81165 81166 81167

    Revisions From 00.06.02x:
    01/01/2019This version of the policy will become effective 01/01/2019.

    Attachment A
    • Barium enema was removed as a screening tool for colorectal cancer screening. The following codes were removed: 74270, 74280, G0106, G0120, G0122.
    • Vitamin D supplements was removed as a preventive service.
    • The following codes were added to the immunizations recommendation: 90672, 90739, 90750.
    Attachment B
    • The following codes were removed from breast cancer screening (mammography): 77061, 77062, 77065, 77066, G0279.
    • Diabetes mellitus screening after pregnancy was added as a preventive service.
    • Urinary incontinence screening was added as a preventive service as part of a preventive exam or well-woman visit.
    • Breastfeeding Support/Counseling and Supplies: The following codes were added to the recommendation: 99401, 99402, 99403, 99404, 99411, 99412.
    Attachment C
    • The following codes were added to the immunizations recommendation: 90672, 90739.
    • Iron supplements was removed as a preventive service.​​​_______________________________________________________
    Note: the policy in Notification was updated 12/26/2018 to include the following changes:
    • The following HCPCS code has been added to the policy: G2011, 90689
    • The policy criteria for Autism and Developmental Screening has been updated to increase the frequency of screenings for the recommended age range.
    • The heading for the diagnosis codes in the Depression Screening service was added.

    Revisions From 00.06.02w:
    10/01/2018The following ICD-10 CM codes have been added to this policy:
    On Attachment B under Depression Screening
      F53.0 Postpartum depression
      F53.1 Puerperal psychosis
      Z13.32 Encounter for screening for maternal depression
    On Attachment A and C under Depression Screening
      Z13.31 Encounter for screening for depression
    The following ICD-10 CM code has been termed from this policy:
      F53 Puerperal psychosis

    Revisions From 00.06.02v:​
    07/01/2018No changes have been made to this version of the policy.

    Effective 10/05/2017 this policy has been updated to the new policy template format.
    10/1/2026
    10/1/2026
    00.06.02
    Claim Payment Policy Bulletin
    Commercial
    {"8754": {"Id":8754,"MPAttachmentLetter":"C","Title":"Pediatric Preventive Care Services","MPPolicyAttachmentInternalSourceId":10956,"PolicyAttachmentPageName":"c2f2ab45-165b-41d4-b257-b8a8e0f77bef"},"8755": {"Id":8755,"MPAttachmentLetter":"A","Title":"Adult Preventive Services","MPPolicyAttachmentInternalSourceId":10958,"PolicyAttachmentPageName":"2aeebea7-7f50-4420-87d7-ab6d2b132709"},"8756": {"Id":8756,"MPAttachmentLetter":"B","Title":"Female Preventive Care Services","MPPolicyAttachmentInternalSourceId":10959,"PolicyAttachmentPageName":"ddaaa71f-9e63-4361-82e0-15a014f21e65"},}
    No
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