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Policy Attachment

MA00.003aa
B
MA00.003aa
Screening Services
Preventive Care Services




BONE MASS MEASUREMENTS

COVERAGE
Bone mass measurements (76977, 77078, 77080, 77081, 77085, G0130) are covered as a preventive service for all individuals.​

FREQUENCY
Bone mass measurements are covered as a preventive service once every 24 months.
If medically necessary, more frequent bone mass measurements (i.e., dual-energy X-ray absorptiometry (axial skeleton)) may be covered as a preventive service in situations such as, but not limited to​ the following:
    • Monitoring individuals on long-term glucocorticoid (steroid) therapy for more than three months
    • Allowing for a confirmatory baseline bone density study for individuals in the future only when a dual-energy X-ray absorptiometry (DXA/DEXA) system (axial skeleton) was not used for the initial measurement
CPT Procedure Code Number(s) and Narratives


76977, 77078, 77080, 77081, 77085

ICD-10 Diagnosis Code Number(s) and Narrative(s)N/A
HCPCS Level II Code Number(s) and Narrative(s)G0130 Single energy x-ray absorptiometry (SEXA) bone density study, one or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel)

CARDIOVASCULAR DISEASE SCREENING BLOOD TESTS

COVERAGE
Cardiovascular disease screening blood tests are covered as a preventive service for individuals without apparent signs or symptoms of cardiovascular disease. Coverage includes tests for total cholesterol, high-density lipoprotein, and triglycerides.

FREQUENCY
Cardiovascular disease screening blood tests are covered as a preventive service once every 5 years.

CPT Procedure Code Number(s) and Narrative(s)80061, 82465, 83718, 84478
ICD-10 Diagnosis Code Number(s) and Narrative(s)Z13.6 Encounter for screening for cardiovascular disorders
HCPCS Level II Code Number(s) and Narrative(s)N/A

COLORECTAL CANCER SCREENING

COVERAGE/FREQUENCY
Colorectal cancer screening is covered as follows:
  • Average-Risk Individuals:
    • Individuals at average-risk for colorectal cancer are covered as a preventive service for any of the following screening tests and procedures: 
      • ​Individuals 45 years of age and older
        • An annual fecal occult blood test (FOBT)*
        • A guaiac-based (gFOBT) or immunoassay-based (iFOBT) test at a frequency of every 12 months
        • Blood-based biomarker test every 3 years when the below criteria are met.
        • Flexible sigmoidoscopy every 48 months
        • Screening barium enema every 48 months as an alternative to a flexible sigmoidoscopy
      • Individuals regardless of age 
        • Screening​ colonoscopy every 10 years (120 months) but not within 48 months of a screening sigmoidoscopy
  • High-Risk Individuals:
    Individuals at high risk* for colorectal cancer are covered as a preventive service for any of the following screening tests and procedures:
    • An annual fecal occult blood test (FOBT)*
      • A guaiac-based (gFOBT) or immunoassay-based (iFOBT) test at a frequency of every 12 months
    • Flexible sigmoidoscopy every 48 months
    • Screening colonoscopy every 24 months but not within 48 months of a screening sigmoidoscopy
      • Screening barium enema every 24 months as an alternative to colonoscopy
* Colorectal cancer screening coverage will be applied based on the ​original intent of the screening colonoscopy or flexible sigmoidoscopy test. A problem may be found and a procedure may be performed concurrently to address the problem (e.g. removal of a polyp). When this occurs, the screening colonoscopy or flexible sigmoidoscopy ​test, the procedure(s) performed concurrently, and the associated services are covered as preventive services, ​not diagnostic services. 

**
gFOBT samples should be taken from two different sites of three consecutive stools. The iFOBT should follow the specific manufacturer's instructions for the appropriate number of stools.

Individuals are considered to be at high-risk for colorectal cancer, if they have any of the following indications:
  • A close relative (i.e., sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp
  • A family history of adenomatous polyposis
  • A family history of hereditary nonpolyposis colorectal cancer
  • A personal history of adenomatous polyps
  • A personal history of colorectal cancer
  • A personal history of inflammatory bowel disease, including Crohn's disease and ulcerative colitis
For those who are eligible for preventive colorectal cancer screening in accordance with the aforementioned criteria, a follow-up colonoscopy after a positive non-invasive stool-based screening test or direct visualization test is considered an important part of the preventive screening. Therefore, a follow-up colonoscopy after a positive non-invasive stool-based screening test or direct visualization test  is considered a preventive service. 

Stool DNA Test - Cologuard

Stool DNA test, Cologuard, is covered as a preventive service every 3 years for individuals who meet all of the following criteria:
  • Age 45 to 85 years
  • Asymptomatic (no signs or symptoms of colorectal disease including but not limited to lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test or fecal immunochemical test), and
  • At average risk of developing colorectal cancer (no personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis; no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer)
Blood-based Biomarker Test

Blood-based biomarker test is covered as a preventive services for average risk individuals every 3 years when the screening test meets all of the following criteria:

  • The test has an FDA market authorization with a colorectal cancer screening indication ​​
  • The test has a sensitivity greater than or equal to 74% in the detection of colorectal cancer compared to colonoscopy based on pivotal studies included in the FDA label.
  • The test has a specificity greater than or equal to 90% in the detection of colorectal cancer compared to colonoscopy based on pivotal studies included in the FDA label.
  • The test is performed in a Clinical Laboratory Improvement Act (CLIA)-certified laboratory
ANESTHESIA
In accordance with Medicare, anesthesia separately furnished in conjunction with screening colonoscopies is considered a covered preventive service. CPT (00811, 00812, 00813)

NOT COVERED
The following colorectal screening tests are not covered by the Company because they are not covered by Medicare. Therefore, they are not eligible for reimbursement consideration.
    • Screening computed tomographic virtual colonoscopy
    • Screening barium enema not used as an alternative to screening sigmoidoscopy or colonoscopy
    • Screening DNA stool assay not otherwise specified above 
BILLING REQUIREMENTS

When all of the preventive criteria are met, a follow-up screening colonoscopy after a positive non-invasive stool-based screening test or direct visualization test is​ only reimbursed when reported with the eligible procedure codes, modifier KX, and the eligible diagnosis code (ICD-10 diagnosis codes Z12.11 or Z12.12​) or the appropriate modifier (modifier 33 or PT). ​​

CPT Procedure Code Number(s) and Narratives81528, 82270

THE FOLLOWING CODES REPRESENT FLEXIBLE SIGMOIDOSCOPY:
The following codes will only be considered preventive when a screening flexible sigmoidoscopy meets all of the preventive criteria and is reported with modifier PT or modifier 33 or ICD-10 diagnosis codes Z12.11 or Z12.12.

45330, 45331, 45333, 45338, 45346, 45349

THE FOLLOWING CODES REPRESENT COLONOSCOPY:
The following codes will only be considered preventive when a screening colonoscopy meets all of the preventive criteria and is reported with modifier PT or modifier 33 or ICD-10 diagnosis codes Z12.11 or Z12.12.

44388, 44389, 44392, 44394, 44401, 44403, 44406, 44407, 45378, 45380, 
45381, 45384, 45385, 45388, 45390

THE FOLLOWING CODE IS USED TO REPRESENT ANESTHESIA ASSOCIATED WITH COLONOSCOPY:

00811, 00812, 00813

NOT COVERED

74263
ICD-10 Diagnosis Code Number(s) and Narrative(s)


Z12.11 Encounter for screening for malignant neoplasm of colon

Z12.12 Encounter for screening for malignant neoplasm of rectum

THE FOLLOWING CODES SHOULD BE USED TO REPORT COLORECTAL CANCER SCREENING FOR INDIVIDUALS AT HIGH RISK:

D12.6 Benign neoplasm of colon, unspecified

K50.00 Crohn's disease of small intestine without complications

K50.011 Crohn's disease of small intestine with rectal bleeding

K50.012 Crohn's disease of small intestine with intestinal obstruction

K50.013 Crohn's disease of small intestine with fistula

K50.014 Crohn's disease of small intestine with abscess

K50.018 Crohn's disease of small intestine with other complication

K50.019 Crohn's disease of small intestine with unspecified complications

K50.10 Crohn's disease of large intestine without complications

K50.111 Crohn's disease of large intestine with rectal bleeding

K50.112 Crohn's disease of large intestine with intestinal obstruction

K50.113 Crohn's disease of large intestine with fistula

K50.114 Crohn's disease of large intestine with abscess

K50.118 Crohn's disease of large intestine with other complication

K50.119 Crohn's disease of large intestine with unspecified complications

K50.80 Crohn's disease of both small and large intestine without complications

K50.811 Crohn's disease of both small and large intestine with rectal bleeding

K50.812 Crohn's disease of both small and large intestine with intestinal obstruction

K50.813 Crohn's disease of both small and large intestine with fistula

K50.814 Crohn's disease of both small and large intestine with abscess

K50.818 Crohn's disease of both small and large intestine with other complication

K50.819 Crohn's disease of both small and large intestine with unspecified complications

K50.90 Crohn's disease, unspecified, without complications

K50.911 Crohn's disease, unspecified, with rectal bleeding

K50.912 Crohn's disease, unspecified, with intestinal obstruction

K50.913 Crohn's disease, unspecified, with fistula

K50.914 Crohn's disease, unspecified, with abscess

K50.918 Crohn's disease, unspecified, with other complication

K50.919 Crohn's disease, unspecified, with unspecified complications

K51.00 Ulcerative (chronic) pancolitis without complications

K51.20 Ulcerative (chronic) proctitis without complications

K51.211 Ulcerative (chronic) proctitis with rectal bleeding

K51.212 Ulcerative (chronic) proctitis with intestinal obstruction

K51.213 Ulcerative (chronic) proctitis with fistula

K51.214 Ulcerative (chronic) proctitis with abscess

K51.218 Ulcerative (chronic) proctitis with other complication

K51.219 Ulcerative (chronic) proctitis with unspecified complications

K51.30 Ulcerative (chronic) rectosigmoiditis without complications

K51.311 Ulcerative (chronic) rectosigmoiditis with rectal bleeding

K51.312 Ulcerative (chronic) rectosigmoiditis with intestinal obstruction

K51.313 Ulcerative (chronic) rectosigmoiditis with fistula

K51.314 Ulcerative (chronic) rectosigmoiditis with abscess

K51.318 Ulcerative (chronic) rectosigmoiditis with other complication

K51.319 Ulcerative (chronic) rectosigmoiditis with unspecified complications

K51.80 Other ulcerative colitis without complications

K51.811 Other ulcerative colitis with rectal bleeding

K51.812 Other ulcerative colitis with intestinal obstruction

K51.813 Other ulcerative colitis with fistula

K51.814 Other ulcerative colitis with abscess

K51.818 Other ulcerative colitis with other complication

K51.819 Other ulcerative colitis with unspecified complications

K51.90 Ulcerative colitis, unspecified, without complications

K51.911 Ulcerative colitis, unspecified with rectal bleeding

K51.912 Ulcerative colitis, unspecified with intestinal obstruction

K51.913 Ulcerative colitis, unspecified with fistula

K51.914 Ulcerative colitis, unspecified with abscess

K51.918 Ulcerative colitis, unspecified with other complication

K51.919 Ulcerative colitis, unspecified with unspecified complications

K52.1 Toxic gastroenteritis and colitis

K52.89 Other specified noninfective gastroenteritis and colitis

K52.9 Noninfective gastroenteritis and colitis, unspecified

Z12.11 Encounter for screening for malignant neoplasm of colon

Z12.12 Encounter for screening for malignant neoplasm of rectum

Z15.09 Genetic susceptibility to other malignant neoplasm

Z80.0 Family history of malignant neoplasm of digestive organs

Z83.710 Family history of adenomatous and serrated polyps

Z83.711 Family history of hyperplastic colon​ polyps

Z83.718 Other family history of colonic polyps

Z83.719 Family history of colonic polyps, unspecified

Z85.038 Personal history of other malignant neoplasm of large intestine

Z85.048 Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus

Z86.004 Personal history of in-situ neoplasm of other and unspecified digestive organs

Z86.010 Personal history of colonic polyps

Z87.19 Personal history of other diseases of the digestive system
HCPCS Level II Code Number(s) and Narrative(s)G0104 Colorectal cancer screening; flexible sigmoidoscopy

G0105 Colorectal cancer screening; colonoscopy on individual at high risk

G0106 Colorectal cancer screening; alternative to G0104, screening sigmoidoscopy, barium enema

G0120 Colorectal cancer screening; alternative to G0105, screening colonoscopy, barium enema

G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk

G0327 Colorectal cancer screening; blood-based biomarker​​

G0328 Colorectal cancer screening; fecal occult blood test, immunoassay, 1-3 simultaneous determinations

NOT COVERED

G0122 Colorectal cancer screening; barium enema
Modifier(s) and Narrative(s)KX Requirements specified in the medical policy have been met

PT Colorectal cancer screening test, converted to diagnostic test or other procedure

33 Preventive Services

Services performed in connection with a preventive colorectal cancer screening procedure

The services listed below when performed in connection with a colorectal cancer screening will be considered preventive when billed with a preventive colonoscopy or flexible sigmoidoscopy.

* Other non-preventive services ( e.g., EGD) even when performed during the same session as a colorectal cancer screening procedure are not considered preventive.

CPT Procedure Code Number(s) and Narrative(s)85014, 85018, 85025, 85027, 94760, 96360, 96365, 96366, 96372, 99100, 
99140, 99152, 99156, 99157
ICD-10 Diagnosis Code Number(s) and Narrative(s)N/A
HCPCS Level II Code Number(s) and Narrative(s)A4246 Betadine or Phisohex solution, per pint

C9285 Lidocaine 70 mg/Tetracaine 70 mg, per patch

G0500 Moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intra-service time; patient age 5 years or older (additional time may be reported with 99153, as appropriate)

J0131 Injection, Acetaminophen,  not otherwise specified, 10 mg

J0171 Injection, Adrenalin, Epinephrine, 0.1 mg

J0290 Injection, Ampicillin Sodium, 500 mg

J0295 Injection, Ampicillin Sodium/Sulbactam Sodium, per 1.5 gram

​J0457 Injection, aztreonam, 100 mg

J0461 Injection, Atropine Sulfate, 0.01 mg

J0665 Injection, bupivicaine, not otherwise specified, 0.5 mg​​

J0670 Injection, Mepivacaine HCL, per 10 mL

J0690 Injection, Cefazolin Sodium, 500 mg

J0692 Injection, Cefepime Hydrochloride, 500 mg

J0694 Injection, Cefoxitin Sodium, 1 Gm

J0696 Injection, Ceftriaxone Sodium, per 250 mg

J0736 Injection, clindamycin phosphate, 300 mg​​

J0744 Injection, Ciprofloxacin for intravenous infusion, 200 mg

J0780 Injection, Prochlorperazine, up to 10 mg

J1170 Injection, Hydromorphone, up to 4 mg

J1200 Injection, Diphenhydramine HCL, up to 50 mg

J1260 Injection, Dolasetron Mesylate, 10 mg

J1335 Injection, Ertapenem Sodium, 500 mg

J1580 Injection, Garamycin, Gentamicin, up to 80 mg

J1626 Injection, Granisetron Hydrochloride, 100 mcg

J1741 Injection, Ibuprofen, 100 mg

J1790 Injection, Droperidol, up to 5 mg

J1810 Injection, Droperidol and Fentanyl Citrate, up to 2 ml ampule

J1836 Injection, metronidazole, 10 mg​​

J1885 Injection, Ketorolac Tromethamine, per 15 mg

J1956 Injection, Levofloxacin, 250 mg

J2001 Injection, Lidocaine HCl for intravaenous infusion, 10 mg

J2010 Injection, Lincomycin HCl, up to 300 mg

J2060 Injection, Lorazepam, 2 mg

J2175 Injection, Merperidine Hydrochloride, per 100 mg

J2180 Injection, Merperidine and Promethazine HCl, up to 50 mg

J2250 Injection, Midazolam Hydrochloride, per 1 mg

J2270 Injection, Morphine Sulfate, up to 10 mg

J2271 Injection, Morphine sulfate, 100 mg

J2275 Injection, Morphine Sulfate (preservative-free solution), per 10 mg

J2300 Injection, Nalbuphine HCL, per 10 mg

J2310 Injection, Naloxone Hydrochloride, per 1 mg

J2311 Injection, Naloxone hydrochloride (zimhi), 1 mg​

J2401 Injection, Chloroprocaine hydrochloride, per 1 mg

J2402 Injection, Chloroprocaine hydrochloride (clorotekal), per 1 mg

J2405 Injection, Ondansetron Hydrochloride, per 1 mg

J2469 Injection, Palonosetron HCl, up to 25 mcg

J2543 Injection, Piperacillin Sodium/Tazobactam Sodium, 1 Gram /0.125 Grams (1.125 Grams)

J2550 Injection, Promethazine HCl, up to 50mg

J2704 Injection, Propofol, 10 mg

J2710 Injection, Neostigmine Methysulfate, up to 0.5 mg

J2765 Injection, Metochlopramide HCl, up to 10 mg

J2795 Injection, Ropivacaine HCL, 1 mg

J2805 Injection, Sincalide, 5 micrograms

J3010 Injection, Fentanyl Citrate, 0.1 mg

J3260 Injection, Tobramycin sulfate, up to 80 mg

J3360 Injection, Diazepam, up to 5 mg

J3370 Injection, Vancomycin HCl, 500 mg

J3410 Injection, Hydroxyzine HCl, up to 25 mg

J3475 Injection, Magnesium Sulfate, per 500 mg

J7040 Infusion, Normal Saline Solution, 500 cc

J7050 Infusion, Normal Saline Solution, 250 cc

J7120 Ringers Lactate Infusion, up to 1000 cc

J8501 Aprepitant, oral, 5 mg

Q0144 Azithromycin dihydrate, oral, capsules/powder, 1 gm

S0028 Injection, Famotidine, 20 mg

S0074 Injection, Cefotetan Disodium, 500 mg

S0119 Ondasetron,oral, 4 mg (for circumstances falling under the Medicare statute, use HCPCS Q code)

S5010 5% Dextrose and 0.45% Normal Saline, 1000 ml
Revenue Code Number(s) and Narrative(s)0250, 0251, 0258, 0260, 0261, 0263, 0270, 0271, 0272, 0370, 0710, 0963, 
0964, 0983

DIABETES SCREENING TESTS

COVERAGE
Diabetes screening tests are covered as a preventive service for individuals who meet either of the following criteria:
    • The individual has any of the following risk factors:
      • Hypertension
      • Dyslipidemia
      • Obesity (a body mass index greater than or equal to 30 kg/m2 )
      • Previous identification of an elevated impaired fasting glucose or glucose tolerance (pre-diabetes*)
    • The individual has at least two of the following characteristics:
      • Overweight (a body mass index greater than 25 but less than 30 kg/m2 )
      • Family history of diabetes
      • Aged 65 years or older
      • A history of gestational diabetes mellitus or delivery of a baby weighing greater than 9 pounds
Diabetes screening tests for individuals previously diagnosed with diabetes are not considered a preventive service and, therefore, are not eligible for coverage under the preventive services benefit.

* Pre-diabetes is a condition of abnormal glucose metabolism diagnosed from a previous fasting glucose level of 100-125 mg/dL or a 2-hour post-glucose challenge of 140-199 mg/dL.

FREQUENCY
The frequency of covered diabetes screening tests ​are twice within a 12-month period. 
CPT Procedure Code Number(s) and Narrative(s)82947, 82950, 82951, 83036
ICD-10 Diagnosis Code Number(s) and Narrative(s)Z13.1 Encounter for screening for diabetes mellitus
HCPCS Level II Code Number(s) and Narrative(s)N/A

GLAUCOMA SCREENING

COVERAGE
Glaucoma screening is covered as a preventive service for individuals in at least one of the following high-risk categories:
    • A diagnosis of diabetes mellitus
    • A family history of glaucoma
    • African-Americans aged 50 or older
    • Hispanic-Americans aged 65 or older
FREQUENCY
Glaucoma screening is covered as a preventive service once every 12 months.

CPT Procedure Code Number(s) and Narrative(s)N/A
ICD-10 Diagnosis Code Number(s) and Narrative(s)Z13.5 Encounter for screening for eye and ear disorders
HCPCS Level II Code Number(s) and Narrative(s)G0117 Glaucoma screening for high risk patients furnished by an optometrist or ophthalmologist

G0118 Glaucoma screening for high risk patient furnished under the direct supervision of an optometrist or ophthalmologist

HEPATITIS B VIRUS (HBV) SCREENING

COVERAGE/FREQUENCY
A Hepatitis B virus screening test is covered as a preventive service for either of the following:
    • Asymptomatic, nonpregnant adolescents and adults at high risk* for HBV infection.
        *High risk for HBV is defined by any of the following:
        • Individuals born in countries and regions with a high prevalence of HBV infection (greater than or equal to 2%)
        • US born persons not vaccinated as infants whose parents were born in regions with a very high prevalence of HBV infection (greater than or equal to 8%)
        • Individuals who are HIV positive
        • Men who have sex with men
        • Injection drug users
        • Household contacts or sexual partners of persons with HBV infection
    • Pregnant individuals during their first prenatal visit.
Repeat screening is covered as a preventive service annually for individuals with continued high risk who have not received the Hepatitis B vaccine.

Repeat screening for pregnant individuals is covered as a preventive service at the time of delivery for those with new or continued risk factors for HBV

CPT Procedure Code Number(s) and Narrative(s)80055, 80081, 86704, 86705, 86706, 87340, 87341
ICD-10 Diagnosis Code Number(s) and Narrative(s)FOR SCREENING FOR HEPATITIS B IN PREGNANT WOMEN, REPORT ONE OF THE FOLLOWING CODES:

Z11.59 Encounter for screening for other viral diseases

AND, ONE OF THE FOLLOWING CODES:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

FOR SCREENING FOR HEPATITIS B IN PREGNANT WOMEN AT INCREASED RISK REPORT ALL OF THE FOLLOWING CODES:

Z11.59 Encounter for screening for other viral diseases

Z72.89 Other problems related to lifestyle

AND, ONE OF THE FOLLOWING CODES:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Z34.93 Encounter for supervision of normal pregnancy, unspecified, third trimester
HCPCS Level II Code Number(s) and Narrative(s)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)

HEPATITIS C VIRUS (HCV) SCREENING

COVERAGE
A Hepatitis C virus antibody screening is covered as a preventive service for the either of the following:
    • Individuals at high risk for hepatitis C virus infection. "High risk" is defined as individuals with a current or past history of illicit injection drug use and/or individuals who received a blood transfusion prior to 1992.
    • Adults who do not meet the high-risk criteria as defined above but were born from 1945 through 1965 once in a lifetime.
For individuals who screen positive for the hepatitis C virus antibody, a confirmatory polymerase chain reaction test is covered.

FREQUENCY
Repeat screening for high-risk individuals is covered as a preventive service every 12 months only for individuals who have had continued illicit injection drug use since the prior negative screening test.

CPT Procedure Code Number(s) and Narrative(s)THE FOLLOWING CODE IS USED TO REPRESENT PRIMARY TESTING FOR HEPATITIS C SCREENING:

86803

THE FOLLOWING CODE IS USED TO REPRESENT SUBSEQUENT CONFIRMATORY TESTING FOR HEPATITIS C SCREENING:

87522
ICD-10 Diagnosis Code Number(s) and Narrative(s)F19.20 Other psychoactive substance dependence, uncomplicated

Z11.59 Encounter for screening for other viral diseases

Z72.89 Other problems related to lifestyle
HCPCS Level II Code Number(s) and Narrative(s)G0472 Hepatitis C antibody screening for individual at high risk and other covered indication (s)

HUMAN IMMUNODEFICIENCY VIRUS (HIV) SCREENING

COVERAGE/FREQUENCY
HIV screening is covered as a preventive service for individuals who are at increased risk for HIV infection, including anyone who requests the test and pregnant individuals.

HIV screening is covered as a preventive service once annually for all adolescents and adults between the age of 15 and 65, without regard to perceived risk.

HIV screening is covered as a preventive service once annually for all adolescents younger than 15 and adults older than 65 who are at increased risk* for HIV infection.

*Increased risk for HIV is defined by any of the following:
    • Men who have had sex with men
    • Individuals having unprotected vaginal or anal intercourse
    • Past or present injection drug users
    • Individuals who exchange sex for money or drugs or who have sex partners who do
    • Individuals who have acquired or request testing for other sexually transmitted infectious diseases
    • Individuals with a history of a blood transfusion between 1978 and 1985
    • Individuals who request an HIV test despite reporting no risk factors
    • Individuals with new sexual partners
    • Individuals whose past or present sex partners were HIV-infected, bisexual, or injection drug users are deemed to be at increased risk for HIV infection.
The determination of "increased risk" for HIV infection is identified by the professional provider who assesses the individual's history, which is part of any complete medical history, typically part of an annual wellness visit and considered in the development of a comprehensive prevention plan

For individuals who are pregnant, HIV screening is covered as a preventive service three times per pregnancy:
    • First, when an individual is diagnosed with pregnancy
    • Second, during the third trimester
    • Third, at labor, if ordered by the professional provider treating the individual
CPT Procedure Code Number(s) and Narrative(s)80081
ICD-10 Diagnosis Code Number(s) and Narrative(s)FOR HIV SCREENING FOR INDIVIDUALS WITHOUT REGARD TO PERCEIVED RISK, REPORT THE FOLLOWING ENCOUNTER CODE:

Z11.4 Encounter for screening for human immunodeficiency virus [HIV]

FOR HIV SCREENING FOR INDIVIDUALS AT INCREASED RISK, REPORT THE FOLLOWING ENCOUNTER CODE:

Z11.4 Encounter for screening for human immunodeficiency virus [HIV]

AND, ONE OF THE FOLLOWING CODES:

Z72.51 High risk heterosexual behavior

Z72.52 High risk homosexual behavior

Z72.53 High risk bisexual behavior

Z72.89 Other problems related to lifestyle

FOR HIV SCREENING FOR PREGNANT WOMEN, REPORT THE FOLLOWING ENCOUNTER CODES:

Z11.4 Encounter for screening for human immunodeficiency virus [HIV]

AND ONE OF THE FOLLOWING CODES:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Z34.93 Encounter for supervision of normal pregnancy, unspecified, third trimester
HCPCS Level II Code Number(s) and Narrative(s)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

LUNG CANCER COUNSELING AND ANNUAL SCREENING USING LOW DOSE COMPUTED TOMOGRAPHY (LDCT)

COVERAGE/FREQUENCY
Lung cancer screening using low dose computed tomography is covered as a preventive service annually when all of the following criteria are met:
    • The individual is age 50–77 years
    • The individual is asymptomatic (no signs or symptoms of lung cancer)
    • The individual has a tobacco smoking history of at least 20 pack-years (one pack-year = smoking one pack per day for one year; 1 pack = 20 cigarettes)
    • The individual is a current smoker or one who has quit smoking within the last 15 years
    • The individual receives a written order for LDCT lung cancer screening that meets the following criteria:
      • For the initial LDCT lung cancer screening service: The individual must receive a written order for LDCT lung cancer screening during a lung cancer screening counseling and shared decision making visit, furnished by a professional provider. A lung cancer screening counseling and shared decision making visit includes the following elements (a​nd is appropriately documented in the medical records):
        • Determination of individual eligibility 
        • Shared decision making, including the use of one or more decision aids, 
        • Counseling on the importance of adherence to annual lung cancer LDCT screening, impact of comorbidities and ability or willingness to undergo diagnosis and treatment;
        • Counseling on the importance of maintaining cigarette smoking abstinence if former smoker; or the importance of smoking cessation if current smoker and, if appropriate, furnishing of information about tobacco cessation interventions
CPT Procedure Code Number(s) and Narrative(s)71271
ICD-10 Diagnosis Code Number(s) and Narrative(s)F17.210 Nicotine dependence, cigarettes, uncomplicated

F17.211 Nicotine dependence, cigarettes, in remission

F17.213 Nicotine dependence, cigarettes, with withdrawal

F17.218 Nicotine dependence, cigarettes, with other nicotine-induced disorders

F17.219 Nicotine dependence, cigarettes, with unspecified nicotine-induced disorders

Z87.891 Personal history of nicotine dependence
HCPCS Level II Code Number(s) and Narrative(s)G0296 Counseling visit to discuss need for lung cancer screening (LDCT) using low dose CT scan (service is for eligibility determination and shared decision making)

PROSTATE CANCER SCREENING 

COVERAGE
Prostate cancer screening with digital rectal examination (DRE) and the prostate-specific antigen (PSA) blood test is covered as a preventive service for individuals aged 50 and older.

FREQUENCY
Prostate cancer screening with DRE and the PSA blood test is covered as a preventive service once every 12 months.

CPT Procedure Code Number(s) and Narrative(s)N/A
ICD-10 Diagnosis Code Number(s) and Narrative(s)Z12.5 Encounter for screening for malignant neoplasm of prostate
HCPCS Level II Code Number(s) and Narrative(s)G0102 Prostate cancer screening; digital rectal examination

G0103 Prostate cancer screening; prostate specific antigen test (PSA)

SCREENING FOR DEPRESSION

COVERAGE
Screening for depression is covered as a preventive service when provided by a primary care professional provider in a primary care setting that has staff-assisted depression care supports in place to ensure accurate diagnosis, effective treatment, and follow-up.

FREQUENCY
Screening for depression is covered as a preventive service once every 12 months.

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)G0444 Annual depression screening, 5 to 15 minutes

SCREENING AND COUNSELING TO REDUCE ALCOHOL MISUSE

COVERAGE
Alcohol misuse screening is covered as a preventive service for ​all individuals.

For individuals who screen positive (those who misuse alcohol but whose levels or patterns of alcohol consumption do not meet criteria for alcohol dependence), counseling is covered as a preventive service when provided by a primary care professional provider in a primary care setting.

FREQUENCY
Alcohol misuse screening is covered as a preventive service once in a 12-month period. For individuals who screen positive, four brief face-to-face counseling sessions for alcohol misuse are covered as a preventive service in a 12-month period.

CPT Procedure C​ode 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)G0442 Annual alcohol misuse screening, 5 to 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

SCREENING MAMMOGRAPHY

COVERAGE/FREQUENCY
A baseline screening mammogram is covered as a preventive service once for females 35 through 39 years of age.

An annual screening mammogram is covered as a preventive service once every 12 months for females 40 years of age and older.

If a screening mammogram turns into a diagnostic mammogram the diagnostic mammogram is covered as a preventive service.

CPT Procedure Code Number(s) and Narrative(s)77063, 77067

The following codes will only be considered preventive when the preventive criteria are met and a screening mammogram turns into a diagnostic mammogram (reported with modifier GH), OR a screening mammogram and diagnostic mammogram are performed on the same day (reported with modifier GG) OR a diagnostic mammogram (reported with modifier 33) is performed on a different date of service as a follow-up to a screening mammogram.

77061, 77062, 77065, 77066
ICD-10 Diagnosis Code Number(s) and Narrative(s)
C84.7A Anaplastic large cell lymphoma, ALK-negative, breast

N61.21 Granulomatous mastitis, right breast

N61.22 Granulomatous mastitis, left breast

N61.23 Granulomatous mastitis, bilateral breast

N63.15 Unspecified lump in the right breast, overlapping quadrants

N63.25 Unspecified lump in the left breast, overlapping quadrants

Z12.31 Encounter for screening mammogram for malignant neoplasm of breast

HCPCS Level II Code Number(s) and Narrative(s)The following code will only be considered preventive when the preventive criteria are met and a screening mammogram turns into a diagnostic mammogram (reported with modifier GH), OR a screening mammogram and diagnostic mammogram are performed on the same day (reported with modifier GG) OR a diagnostic mammogram (reported with modifier 33) is performed on a different date of service as a follow-up to a screening mammogram.

G0279 Diagnostic digital breast tomosynthesis, unilateral or bilateral (list separately in addition to 77065 or 77066)
Modifier(s) and Narrative(s)GG Performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day

GH Diagnostic mammogram converted from screening mammogram on same day.

33 Preventive Services

SCREENING PELVIC EXAMS (INCLUDING A CLINICAL BREAST EXAM) AND PAPANICOLAOU (PAP) TESTS

COVERAGE/FREQUENCY
Screening pelvic exams (including a clinical breast exam) and papanicolou (Pap) tests are both covered as a preventive service:
    • Once every 24 months (or 23 months following the month of the last covered exam) for females at normal risk for developing cervical or vaginal cancer
    • Once every 12 months (or 11 months following the month of the last covered exam) if the female is at high risk* of developing cervical or vaginal cancer
    • Once every 12 months (or 11 months following the month of the last covered exam) if the female is of childbearing age with an abnormal Pap test within the past three years
High-risk factors for cervical or vaginal cancer include the following:
    • Early onset of sexual activity (aged 16 and younger)​
    • Multiple sexual partners (five or more in a lifetime)
    • History of a sexually transmitted disease (including human immunodeficiency virus [HIV] infection)
    • Fewer than three negative Pap tests or no Pap test within the previous seven years
    • DES (diethylstilbestrol)-exposed daughters of women who took DES during pregnancy
CPT Procedure Code Number(s) and Narrative(s)SCREENING PELVIC EXAMS (INCLUDING A CLINICAL BREAST EXAM)

99383, 99384, 99385, 99386, 99387, 99393, 99394, 99395, 99396, 99397

ADD-ON CPT CODE 99459 WILL ONLY BE COVERED AS A PREVENTIVE SERVICE WHEN REPORTED WITH PRIMARY PROCEDURE CODES 99383, 99384, 99385, 99386, 99387, 99393, 99394, 99395, 99396, 99397 AND WITH THE DIAGNOSIS CODES BELOW:

99459
ICD-10 Diagnosis Code Number(s) and Narrative(s)SCREENING PELVIC EXAMS (INCLUDING A CLINICAL BREAST EXAM) AND PAPANICOLAOU (PAP) TESTS WHEN THE INDIVIDUAL IS CONSIDERED TO BE HIGH RISK OR HAS AN ABNORMAL PAP TEST ARE COVERED FOR THE FOLLOWING CONDITIONS:

R87.610 Atypical squamous cells of undetermined significance on cytologic smear of cervix (ASC-US)

R87.611 Atypical squamous cells cannot exclude high grade squamous intraepithelial lesion on cytologic smear of cervix (ASC-H)

R87.612 Low grade squamous intraepithelial lesion on cytologic smear of cervix (LGSIL)

R87.613 High grade squamous intraepithelial lesion on cytologic smear of cervix (HGSIL)

R87.614 Cytologic evidence of malignancy on smear of cervix

R87.618 Other abnormal cytological findings on specimens from cervix uteri

R87.619 Unspecified abnormal cytological findings in specimens from cervix uteri

R87.620 Atypical squamous cells of undetermined significance on cytologic smear of vagina (ASC-US)

R87.621 Atypical squamous cells cannot exclude high grade squamous intraepithelial lesion on cytologic smear of vagina (ASC-H)

R87.622 Low grade squamous intraepithelial lesion on cytologic smear of vagina (LGSIL)

R87.623 High grade squamous intraepithelial lesion on cytologic smear of vagina (HGSIL)

R87.624 Cytologic evidence of malignancy on smear of vagina

R87.628 Other abnormal cytological findings on specimens from vagina

R87.629 Unspecified abnormal cytological findings in specimens from vagina

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

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

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

Z77.29 Contact with and (suspected) exposure to other hazardous substances

Z77.9 Other contact with and (suspected) exposures hazardous to health

Z91.89 Other specified personal risk factors, not elsewhere classified

Z92.850 Personal history of Chimeric Antigen Receptor T-cell therapy

Z92.858 Personal history of other cellular therapy

Z92.86 Personal history of gene therapy

Z92.89 Personal history of other medical treatment

SCREENING PELVIC EXAMS (INCLUDING A CLINICAL BREAST EXAM) AND PAPANICOLAOU (PAP) TESTS WHEN THE INDIVIDUAL IS CONSIDERED TO BE NORMAL RISK ARE COVERED FOR THE FOLLOWING CONDITIONS:

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

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

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

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

Z12.4 Encounter for screening for malignant neoplasm of cervix

Z12.72 Encounter for screening for malignant neoplasm of vagina

Z12.79 Encounter for screening for malignant neoplasm of other genitourinary organs

Z12.89 Encounter for screening for malignant neoplasm of other sites
HCPCS Level II Code Number(s) and Narrative(s)SCREENING PAPANICOLAOU (PAP) TESTS

G0123 Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, screening by cytotechnologist under physician supervision

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

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

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

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

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

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

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

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

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

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

SCREENING PELVIC EXAMS (INCLUDING A CLINICAL BREAST EXAM)

G0101 Cervical or vaginal cancer screening; pelvic and clinical breast examination

S0610 Annual gynecological examination, new patient

S0612 Annual gynecological examination, established patient

S0613 Annual gynecological examination; clinical breast examination without pelvic evaluation

SCREENING FOR HUMAN PAPILLOMAVIRUS (HPV)

COVERAGE/FREQUENCY
Human Papillomavirus (HPV) screening in conjunction with a pap smear test is covered as a preventive service once every five years for asymptomatic individuals aged 30 to 65 years.

CPT Procedure Code Number(s) and Narrative(s)N/A
ICD-10 Diagnosis Code Number(s) and Narrative(s)Z11.51 Encounter for screening for human papillomavirus (HPV)

AND

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

OR

Z01.419 Encounter for gynecological examination (general) (routine) without abnormal findings
HCPCS Level II Code Number(s) and Narrative(s)G0476 Infectious agent detection by nucleic acid (dna or rna); human papillomavirus (HPV), high-risk types (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) for cervical cancer screening, must be performed in addition to pap test

SCREENING FOR SEXUALLY TRANSMITTED INFECTIONS (STIs) AND HIGH-INTENSITY BEHAVIORAL COUNSELING (HIBC) TO PREVENT STIs

COVERAGE/FREQUENCY
Screening for Sexually Transmitted Infections (STIs)

Screenings for chlamydia and gonorrhea are covered as a preventive service for:
    • Women at increased risk* who are not pregnant. One screening every 12 months is covered.
    • Pregnant women who are 24 years old or younger when the diagnosis of pregnancy is known, and then repeat screening during the third trimester if high-risk* behavior has occurred since the initial screening test.
    • Pregnant women who are at increased risk* for STIs, regardless of age, when the diagnosis of pregnancy is known, and then repeat screening during the third trimester if high-risk behavior* has occurred since the initial screening test
Screening for syphilis is covered as a preventive service for:
    • Women at increased risk* for STIs who are not pregnant. One screening every 12 months is covered.
    • Pregnant women, regardless of age, when the diagnosis of pregnancy is known, and then repeat screening during the third trimester and at delivery if high-risk* behavior has occurred since the previous screening test.
    • Men at increased risk* for STIs. One screening every 12 months is covered.
High-Intensity Behavioral Counseling (HIBC)

Face-to-face high-intensity behavioral counseling (HIBC) sessions (lasting 20-30 minutes) for sexually active individuals at increased risk* for STIs are covered as a preventive service if they are provided by a primary care professional provider and take place in a primary care setting. Up to two HIBC counseling sessions are covered every 12 months.

High-risk/increased risk behaviors posing an increased risk for STIs include any of the following:
    • Multiple sex partners
    • Using barrier protection inconsistently
    • Having sex under the influence of alcohol or drugs
    • Having sex in exchange for money or drugs
    • Age (risk for chlamydia and gonorrhea in sexually active women 24 years of age or younger)
    • Having an STI within the past year
    • In addition, for men, men having sex with men (MSM) and engaged in high-risk sexual behavior, regardless of age
CPT Procedure Code Number(s) and Narrative(s)USE ONE OF THE FOLLOWING CODES TO REPORT SCREENING FOR CHLAMYDIA:

86631, 86632, 87110, 87270, 87320, 87490, 87491, 87810

USE ONE OF THE FOLLOWING CODES TO REPORT SCREENING FOR GONORRHEA:

87590, 87591, 87850

USE ONE OF THE FOLLOWING CODES TO REPORT COMBINED SCREENING FOR CHLAMYDIA AND GONORRHEA:

​​​​​​​0402U, 87800

USE ONE OF THE FOLLOWING CODES TO REPORT SCREENING FOR SYPHILIS:

86592, 86593, 86780
ICD-10 Diagnosis Code Number(s) and Narrative(s)FOR SCREENING FOR CHLAMYDIA, GONORRHEA, OR SYPHILIS IN NON-PREGNANT WOMEN AT HIGH RISK, REPORT THE FOLLOWING CODES:

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

AND ANY OF THE FOLLOWING:

Z72.51 High risk heterosexual behavior

Z72.52 High risk homosexual behavior

Z72.53 High risk bisexual behavior

Z72.89 Other problems related to lifestyle

FOR SCREENING FOR SYPHILIS IN MEN AT HIGH RISK, REPORT THE FOLLOWING CODES:

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

AND ANY OF THE FOLLOWING:

Z72.51 High risk heterosexual behavior

Z72.52 High risk homosexual behavior

Z72.53 High risk bisexual behavior

Z72.89 Other problems related to lifestyle

FOR SCREENING FOR CHLAMYDIA, GONORRHEA OR SYPHILIS IN PREGNANT WOMEN AT HIGH RISK REPORT THE FOLLOWING CODES

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

AND ANY OF THE FOLLOWING:

Z72.51 High risk heterosexual behavior

Z72.52 High risk homosexual behavior

Z72.53 High risk bisexual behavior

Z72.89 Other problems related to lifestyle

AND REPORT ONE OF THE FOLLOWING CODES

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

FOR HIGH-INTENSITY BEHAVIORAL COUNSELING (HIBC) FOR INDIVIDUALS AT INCREASED RISK REPORT THE FOLLOWING CODE:

Z72.89 Other problems related to lifestyle
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

ULTRASOUND SCREENING FOR ABDOMINAL AORTIC ANEURYSM (AAA)

COVERAGE
Ultrasound screening for abdominal aortic aneurysm (AAA) is covered as a preventive service for individuals with one of the following risk factors when the individual receives a referral from their professional provider:
    • A family history of AAA
    • Males 65 through 75 years of age who have smoked at least 100 cigarettes in their lifetime
FREQUENCY
Ultrasound screening for abdominal aortic aneurysm (AAA) is covered as a preventive service once in a lifetime.

CPT Procedure Code Number(s) and Narratives76706
ICD-10 Diagnosis Code NumberZ13.6 Encounter for screening for cardiovascular disorders

Z82.49 Family history of ischemic heart disease and other diseases of the circulatory system

Z87.891 Personal history of nicotine dependence
HCPCS Level II Code Number(s) and NarrativesN/A

MISCELLANEOUS

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)

10/01/2024
10/02/2024
N/A
Medical Policy Bulletin
Medicare Advantage
aaf9edcf-bf71-47de-a5f1-e09b853b1422
Yes