Medicare preventive services/codes

Preventive health services are covered at $0 cost sharing, so it's important to follow Medicare billing rules when submitting claims.

See the Medicare Learning Network's preventive billing guidelines or the Medicare Quick Reference Guide.

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Preventive physical exams

Members are eligible for one routine preventive physical exam each benefit year, no sooner than 11 months from the previous routine physical exam. This is a supplemental benefit offered to Priority Health Medicare members since Medicare does not cover physicals. Members, however, may receive an annual wellness exam (see below for more information) by itself or with a preventive physical exam. When multiple exams are done on the same day, bundling edits may apply.

  • Verify with patients that they have not already had either an annual wellness or preventive physical exam from their primary care physician. This will avoid duplicate, non-medically necessary services; for example, when only a well-woman gynecological visit is needed.
  • Report the annual wellness exam by using the HCPCS codes on the Quick Reference Chart (see also below under Annual wellness exam).
  • Report a preventive physical exam with preventive medicine codes 99381-99387 (new patient) and 99391-99397 (established patient).
  • Use modifier 52 to report a preventive physical exam that's given on the same day in addition to an annual wellness exam.

"Welcome to Medicare" preventive visit

This visit is covered once in a lifetime in addition to the annual physical exams covered as a supplemental benefit under our Priority Health Medicare plans. This is used when the member is new to Medicare (i.e. within 12 months of his/her first effective date with Part B Medicare coverage).

Priority Health does not reimburse for an initial preventive physical (Welcome to Medicare physical) G0402 when performed on the same date as other preventive medicine exams/services since several components overlap. You may submit documentation for retrospective review if medical records support significant, separately identifiable services.

Providers should bill using these Medicare-allowed codes:

  • G0402 - Welcome to Medicare visit
  • G0403 - EKG* with Welcome to Medicare visit
  • G0404 - EKG* tracing for Welcome to Medicare visit
  • G0405 - EKG* interpretation & report for Welcome to Medicare visit.

*Screening EKG is an optional service that may be performed as a result of a referral from a Welcome to Medicare visit.

Annual wellness visit, G0438, G0439

This is an annual benefit available to all Medicare beneficiaries more than 12 months after the effective date of their Medicare Part B coverage period AND who have not received a Welcome to Medicare visit or annual wellness visit within the past 12 months.

Providers should bill using:

  • G0438 - Initial annual wellness visit (one per lifetime)
  • G0439 - Subsequent annual wellness visit

See above under preventive physical exam for information on how to bill for an annual wellness visit in conjunction with a physical. 

For information about annual wellness visit see this Medicare Learning Network brochure on the CMS website.

Advance care planning

Medicare covers advanced care planning as a preventive health service when part of the annual wellness visit, when patient consent is documented in the medical record. See our advanced care planning page for how to bill for ACP at the preventive health benefit level.

Preventive screening lab tests

Some Medicare-covered preventive services include preventive screening labs. These must be ordered according to Medicare rules to be covered (see the CMS Quick Reference Chart linked above). Members of Priority Health Medicare Advantage plans have a $0 copay for these services when billed correctly. If you are unsure about whether a lab is covered, follow the pre-service organization determination process.

Not covered:

Priority Health Medicare does not cover labs, including blood tests, when:

  • Billed in conjunction with a routine or general physical exam, or
  • Billed with a diagnosis code of Z00.00

General health panel, 80050

Not covered by Original Medicare.

In 2018, 80050 is no longer covered by Priority Health Medicare plans.

Cardiovascular screening blood tests, 80061, 82465, 83718, 84478

Every 5 years for all Medicare beneficiaries without apparent signs or symptoms of cardiovascular disease

Diabetes screening tests, 82947, 82950, 82951

Two screening tests/year without diabetes; one/year if previously tested but not diagnosed with pre-diabetes, or if never tested, for all Medicare beneficiaries with certain risk factors for diabetes

Prostate cancer screening, G0102 (DRE) and G0103 (PSA)

Annually for all male Medicare beneficiaries age 50 and older (coverage begins the day after 50th birthday)

Human Immunodeficiency Virus (HIV) screening, G0432, G0433, G0435, G0475

Annually for those at increased risk; three times per pregnancy. For more information on Screening for HIV infection, see MM6786. "Individuals at increased risk for HIV" is defined in Medicare National Coverage Determinations Manual, sections 190.14 (diagnostic) and 210.7 (screening)

Sexually Transmitted Infections (STIs)

See the Medicare Quick Reference Guide for coding, frequency of tests and who's covered. See also MM7610

Screening Pap tests and pelvic exams, P3000, P3001, Q0091, G0101

Medicare covers screening Pap tests and pelvic exams once every 24 months for women at low risk of cancer, more often for women at high risk.

Use screening Pap test codes P3000, P3001 or Q0091 when billing with these diagnosis codes:

  • Low risk - V72.31, V76.2, V76.47, and V76.49
  • High risk - V15.89

Use screening pelvic exam code G0101 when billing with these diagnosis codes:

  • Low risk - V72.31, V76.2, V76.47, and V76.49
  • High risk - V15.89

G0101 and/or Q0091: Do not report with a preventive medicine E&M code when billed by the same provider on the same date of service.

See the Medicare Network Learning brochures on screening pelvic exams or screening pap test.

Bone mass measurement exams, 76977, 77078-77081, 77083, G0130

Medicare covers bone mass measurement exams every 24 months, or more frequently if medically necessary, for:

  • Women determined by their physician or qualified non-physician practitioner to be estrogen deficient and at clinical risk for osteoporosis
  • Individuals with vertebral abnormalities
  • Individuals receiving (or expecting to receive) glucocorticoid therapy for more than 3 months
  • Individuals with primary hyperparathyroidism
  • Individuals being monitored to assess response to FDA-approved osteoporosis drug therapy

For covered diagnoses, refer to NCD 150.3, Bone (Mineral) Density Studies.

Colorectal cancer screenings

Medicare covers colorectal cancer screenings for Medicare beneficiaries ages 50 and older who are at normal risk or high risk of developing colorectal cancer. High risk for developing colorectal cancer is defined in 42 CFR 410.37(a)(3). Bill screening exams as follows:

G0104, Flexible Sigmoidoscopy

Once every 4 years after a previous screening colonoscopy for people not at high risk or 120 months after previous screening colonoscopy for people not a high risk

G0105, Colonoscopy (high risk)

Every 24 months for individuals at high risk or 48 months after flexible sigmoidoscopy

G0106, Barium Enema (alternative to G0104)

Every 48 months after a previous flexible sigmoidoscopy and every 24 months for individuals at high risk

G0120, Barium Enema (alternative to G0105)

Every 48 months after a previous flexible sigmoidoscopy and every 24 months for individuals at high risk

G0121, Colonoscopy (not high risk)

Every 10 years

G0328, Fecal Occult Blood Test (FOBT), immunoassay, 1-3 simultaneous

Every year

82270, BOFT (blood, occult, by peroxidase

Every year

Hepatitis C screening (HCV), G0472

Medicare covers a screening for the Hepatitis C virus (HCV) consistent with the grade B recommendations by the United States Preventive Services Task Force (USPSTF) for the prevention or early detection of an illness or disability and is appropriate for Medicare beneficiaries.

Adults born from 1945 through 1965: A single screening (once/lifetime) is covered for adults who do not meet the high-risk definition below.

Adults at high risk for HCV infections: Repeat screening is covered annually only for persons who have had continued illicit injection drug use since the prior negative screening test. "High risk" is defined as having a current or past history of illicit injection drug use, or those who received a blood transfusion prior to 1992. The determination of "high risk for HCV" is identified by the primary care physician or practitioner who assesses the patient'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. The medical record should be a reflection of the service(s) provided.

To bill for the hepatitis C screening:

  • Single screening: Submit code G0472. 
  • Adults at high risk, initial screening: Submit Code G0427 with Z72.89 (other problems related to life style).
  • Adults at high risk, subsequent annual screenings: Code G0472 with ICD Dx V69.8/Z72.89 and ICD Dx 304.91 (unspecified drug dependence), continuous/F19.20 (other psychoactive substance abuse, uncomplicated

See MLN Matters MM8871 NOTE: Priority Health Medicare Advantage plan benefits are 12-month benefits. Therefore the Original Medicare rule of 11 months stated in the MLN Matters article does not apply to our plans.

Immunizations

See separate information in this part of the Provider Center:

Intensive behavioral counseling

Medicare covers intensive behavioral counseling when provided by a qualified primary care physician or other primary care practitioner in the primary care setting for the following conditions.

Cardiovascular disease intensive behavioral counseling, G0446

Medicare covers intensive behavioral counseling annually for:

  • Men aged 45-79 and women aged 55 through 79, to encourage the use of aspirin for primary prevention of cardiovascular disease when benefits outweigh risks.
  • Adults 18 or older, a screening for high blood pressure. 
  • Adults with hyperlipidemia, hypertension, advancing age, and other known cardiovascular-and diet-risk factors, intensive behavioral counseling to promote a healthy diet.

For additional information see the Medicare Learning Network.

Obesity intensive behavioral counseling, G0447

Medicare covers face-to-face behavioral counseling for individuals with BMIs > 30 kg/m2 who are competent and alert at time of the counseling. Frequency of visits is as follows:

  • One visit/week for 1st month
  • One visit/every other week for months 2-6; and
  • One visit/month for months 7-12

At the 6-month visit, reassess the level of obesity and determine the amount of weight loss. Individuals who achieve a weight loss of at least 3kg are eligible for additional counseling visits. If they have not, wait 6 months and then reassess their readiness to change and their BMI.

Report one of these diagnosis codes: V85.30-85.39, V85.41-V85.45.

For more information see the Medicare Learning Network publication on ITB for obesity.

Depression screenings, G0444

Medicare covers an annual screening for depression when provided by a qualified primary care physician or other primary care practitioner in the primary care setting.

This is available to all Medicare beneficiaries. For additional information see the Medicare Learning Network publication on screening for depression.

Depression screenings with Annual Wellness Visit G0439

Depression screenings will be considered bundled when reported with the same encounter as the annual wellness visit (AWV) (HCPCS G0439).  This is based on the Medicare guideline outlined below and per the HCPCS description of G0439.

  • When performed in conjunction with the AWV, the depression screening is reimbursed as a component of the annual wellness visit service and meets the annual benefit available to the member.
  • If the member didn’t receive the AWV and provider performs G0444, this service would be reimbursed per their annual benefit.

The Medicare Benefit Policy Manual guidelines from Chapter 15 under section Annual Wellness Visit (AWV), states that an Annual Wellness Visit includes: "Review of the individual's potential (risk factors) for depression, including current or past experiences with depression or other mood disorders, based on the use of an appropriate screening instrument for persons without a current diagnosis of depression, which the health professional may select from various available standardized screening tests designed for this purpose and recognized by national medical professional organizations."

Alcohol screenings and counseling, G0442

Medicare covers screening and behavioral counseling for all Medicare beneficiaries when provided by a qualified primary care physician or other primary care practitioner in the primary care setting. All Medicare beneficiaries are eligible for an annual screening.

Beneficiaries who misuse alcohol but whose levels and patterns do not meet alcohol dependence levels are eligible for counseling if they are competent and alert at time of the counseling. Counseling is available four times a year. Also see the Medicare Learning Network article.

Counseling to prevent tobacco use for asymptomatic members

Medicare covers counseling to prevent tobacco use for beneficiaries in outpatient and hospital settings regardless of whether they have signs or symptoms of tobacco-related disease, if they are competent and alert at time the counseling is provided and when counseling is furnished by a qualified physician or other Medicare-recognized practitioner.

  • Two cessation attempts per year are covered.
  • Each attempt includes 4 intermediate or intensive sessions, up to 8 in a 12 month period.
  • Qualified providers should bill using either 305.1 or V15.82.
  • See also MM7133.