Preventive services/codes

Applies to:

Group commercial HMO, EPO, POS and PPO plans

Individual MyPriority® HMO, POS and PPO plans

Medicaid preventive services are determined by plan documents from the State of Michigan.

Definition:

Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems, when the member has no symptoms.

Clinical practice guidelines

Preventive services billing

These codes correlate to services listed in our Preventive Health Care Guidelines, which apply to members of group HMO, POS and PPO plans and individual MyPriority® plans. Use this chart for reference only; refer to the current CPT manual for a complete description of each code and the most updated code lists.

Exceptions:

  • Self-funded employer groups may individualize their plan benefits, which may override the Preventive Health Care Guidelines.
  • Some "grandfathered" plans may have copays for preventive services, and/or a different list of preventive services.
  • Certain religious employers can claim exemption from the contraceptive methods, counseling and sterilizations for women.
  • Certain religious organizations can claim a safe harbor exemption from covering contraceptive methods and counseling.
  • Medicaid coverage is primarily determined by the State of Michigan. If no Medicaid-specific preventive coverage documentation exists, our preventive guidelines will apply.

Preventive service codes

Service HCPCS/CPT codes Required ICD-10
diagnosis code
Guideline/source
ABDOMINAL AORTIC ANEURYSM SCREENING: Aortography 76706

Not specified

  • Men age 65-75
  • History of smoking
  • Once per lifetime
  • USPSTF Rating: B
ADVANCE CARE PLANNING 99497, 99498 Not specified

At time of physical exam - payable to professional only

See details

BRCA SCREENING Testing: 81211, 81212, 81213, 81214, 81215, 81216, 81217
Counseling: 96040, S0265

Z80.3, Z80.41, Z80.49, Z85.3, Z85.43, Z15.01

  • Women at high risk for breast or ovarian cancer
  • USPSTF Rating: B
  • Once per lifetime
BREAST CANCER SCREENING:
Mammography
77063, 77067
Not specified
  • Women age 30-49 high risk
  • Women age 50-74
  • Every 2 years
  • USPSTF Rating: B

See medical policy 91545, Breast Related Procedures

77065, 77066
77051 (billed when screening turns diagnostic; screening diagnosis required)

Z85.3, Z80.3, Z12.31, Z12.39

Service HCPCS/CPT codes Required ICD-10
diagnosis code
Guideline/source
CERVICAL CANCER SCREENING (lab/path):
PAP smear

G0123, G0124, G0141, G0142, G0143, G0144, G0145, G0146, G0147, G0148

88141-88155*, 88164*, 88165*, 88166*, 88167*, 88174*, 88175*

Not specified for G codes

Z00.00-Z00.01, Z00.121-Z00.129, Z01.411, Z01.419, Z12.4, Z12.72, Z72.51-Z72.53, Z80.41, Z80.49

  • Women
  • Age 21-61
  • Every 3 years
  • USPSTF Rating: A
CERVICAL CANCER SCREENING (lab/path):
Human Papillomavirus (HPV)

87623*, 87624*, 87625*

Z00.00-Z00.01, Z00.121 - Z00.129, Z01.411, Z01.419, Z11.3, Z11.4, Z11.51, Z11.59, Z12.4, Z12.72, Z7.189, Z72.51-Z72.53, Z80.41, Z80.49

 

  • Women 30-65
  • With PAP smear
  • Every 5 years
  • HHS Requirement

COLORECTAL CANCER SCREENING:
Colonoscopy, sigmoidoscopy

45330*, 45331*, 45333*, 45334*, 45335*, 45338*, 45346*, 45378*, 45380*, 45381*, 45382*, 45383*, 45384*, 45385*, 45388*
G0104, G0105, G0121

Z12.11-Z12.12, Z80.0, Z83.71, Z85.00-Z85.09, Z86.010

  • Colonoscopy performed for screening purposes converted to diagnostic; bill with modifier 33 or PT
  • Age 50-75 years 
  • Screening sigmoidoscopy performed every 5 years
  • Screening colonoscopy should be performed every 10 years
  • USPSTF Rating: A

See medical policy 91547, Colorectal Cancer Screening

Facility charges for surgical/treatment room, supplies, anesthesia (00812), medication.

Anesthesia code 00812, 99152*, 99153*, 99156*, 99157* should be billed with modifier PT or 33 if procedure is converted from screening to therapeutic.

Pathology: 88305

Office visit/consult with gastroenterologist before screening colonoscopy if medically necessary: S0285

Z12.11-Z12.12, Z80.0, Z83.71, Z85.00-Z85.01, Z85.020, Z85.028, Z85.030, Z85.038, Z85.040, Z85.048, Z85.810, Z85.818, Z85.819, Z86.010

COLORECTAL CANCER SCREENING:
CT colonography
74623 Not specified; prior authorization required
  • Age 50-75 years
  • Every 10 years
  • USPSTF Rating: I
COLORECTAL CANCER SCREENING:
Fecal DNA (Cologuard)
81528 See medical policy 91547, Colorectal Cancer Screening
  • Age 50-75 years
  • Every 3 years
  • USPSTF Rating: A
  • COLORECTAL CANCER SCREENING:
    Fecal occult blood (FOB)
    82270*, 82274*, G0328

    Z00.00-Z00.01, Z12.11-Z12.12, Z80.0, Z83.71, Z85.00-Z85.01, Z85.020, Z85.028, Z85.030, Z85.038, Z85.040, Z85.048, Z85.810, Z85.818, Z85.819, Z86.010

    • Age 50-75 years 
    • Annually
    • USPSTF Rating: A
    Service HCPCS/CPT codes Required ICD-10
    diagnosis code
    Guideline/source
    CONTRACEPTION:
    Pregnancy test in relation to contraceptive services
    81025

    Z30.011-Z30.09; Z30.40-Z30.9, Z31.61-Z31.69, Z97.5

    • Refer to plan documents to verify coverage
    • HRSA requirement
    • Anesthesia, radiology and other ancillary services in conjunction with CM services may be medically necessary but are not routine and will not be covered as preventive benefits.
    CONTRACEPTION:
    Diaphragm, cervical cap, vaginal ring, etc.
    57170, A4261, A4266, J7303, J7304
    CONTRACEPTION:
    Intrauterine device (IUD)
    58300, 58301, J7296, J7297, J7298, J7300, J7301
    CONTRACEPTION:
    Implantable capsule
    11976, 11981, 11982, 11983, J7306, J7307
    CONTRACEPTION:
    Depo Provera
    J1050, 96372
    Service HCPCS/CPT codes Required ICD-10
    diagnosis code
    Guideline/source
    DEVELOPMENTAL\AUTISM SCREENING 96110 Not specified
    • Age 9, 18 and 24 months
    • Not payable for facility provider
    • HRSA via Bright Futures
    DIABETES SCREENING
    82947*, 82948*, 83036*

    Z00.00-Z00.01, Z00.121-Z0.129, Z01.411, Z01.419, Z13.1, I10 (Hgb A1C)

    • Elevated blood pressure or hyperlipidemia
    • USPSTF Rating: B
    DIETARY COUNSELING 97802, 97803, 97804 Not specified
    • Dietician services as needed for risk of diet related disease
    • Limited to 6 visits/plan year
    • USPSTF Rating: B
    FLOURIDE VARNISH APPLICATION 99188 Not specified
    • Application by PCP to primary teeth of infants and children to age 5
    • USPSTF Rating: B
    HEARING SCREENING 92551, V5008

    Not specified

    • Newborn & age 3, 4, 6, 8, 10, 12, 15, 18 years
    • USPSTF Rating: B
    • HRSA via Bright Futures
    HEMOGLOBIN or HEMATACRIT 85014*, 85018*

    Z00.00-Z00.01, Z00.110-Z00.3, Z01.411, Z01.419, Z76.1, Z76.2

    • Ages 0-18 years only
    • 1x at 12 months
    • 1x between 11-18 years
    • Annually for menstruating adolescents
    • HRSA via Bright Futures
    Service HCPCS/CPT codes Required ICD-10
    diagnosis code
    Guideline/source
    HEPATITIS B SCREENING 86704 - 86707*, 87340*

    Z00.00-Z00.01, Z01.411, Z01.419, Z11.59, Z72.89

    • Persons at high risk for infection (sexually transmitted disease and shared needles)
    • USPSTF Rating: B
    HEPATITIS C SCREENING 86803*
    G0472

    Z00.00-Z00.01, Z01.411, Z01.419, Z11.59, Z72.89

    • High risk adults or one time for individuals born between 1945-1965
    • USPSTF Rating: B
    HYPERLIPIDEMIA TESTING:
    Lipid panel
    80061*

    Z00.00-Z00.01, Z00.121-Z00.129, Z01.411-Z01.419, Z13.220, Z13.6

    • Adults: every 5 years
    • Children: if identified at high risk
    • USPSTF Rating: A
    • HRSA via Bright Futures
    HYPERLIPIDEMIA TESTING:
    Total cholesterol, HDL, LDL, triglycerides
    82465*, 83718*, 83721*, 84478*
    LEAD TESTING 83655*

    Z00.00-Z00.01, Z00.121, Z00.129, Z77.011

    HRSA
    LUNG CANCER SCEENING
    Low-dose chest CT scan: G0297
    Counseling: G0296
    Not specified
    Prior authorization required for the CT scan
    • Annual screen
    • Age 55-80
    • 30-pack year history
    • Current smoker or quit in past 15 years
    • USPSTF rating: B
    OSTEOPOROESIS SCREENING: Central/axial DEXA scan 77080*, 77085*

    Z00.00, Z00.01, Z13.820, Z78.0

    • Women Age 65+ or at high risk
    • USPSTF Rating: B

    See medical policy 91494, Bone Density Studies

    Service HCPCS/CPT codes Required ICD-10
    diagnosis code
    Guideline/source
    SEXUALLY TRANSMITTED INFECTION TESTING:
    HIV
    G0432-G0433, G0435, 86701*, 86702*, 86703*, 87806*, 87389*

    Not specified for G codes

    Z00.00-Z00.01, Z01.411, Z01.419, Z11.3, Z11.4, Z11.59, Z71.7, Z71.89, Z72.51-Z72.53

    • Annual for adults at high risk
    • USPSTF Rating: A
    • HRSA for women
    SEXUALLY TRANSMITTED INFECTION TESTING:
    Syphilis
    86592*

    Z00.00-Z00.01, Z01.411-Z01.419, Z11.3, Z71.89, Z72.51-Z72.53

    USPSTF Rating: A
    SEXUALLY TRANSMITTED INFECTION TESTING:
    Gonorrhea
    87850*, 87590*, 87591*, 87592*

    Z00.00-Z00.01, Z00.121 – Z00.129, Z01.411-Z01.419, Z11.3, Z71.89, Z72.51-Z72.53

    USPSTF Rating: A
    SEXUALLY TRANSMITTED INFECTION TESTING:
    Chlamydia
    87110*, 87270*, 87320*, 87490*, 87491*, 87492*

    Z00.00-Z00.01, Z00.121-Z00.129, Z01.411-Z01.419, Z11.3, Z11.8, Z71.89, Z72.51-Z72.53

    • USPSTF Rating: A
    • Women only
    STERILIZATION:
    Tubal occlusion device
    58565 (includes implant), 58615, 58340, 74740

    Z30.2, Z98.51

    • Women only
    • Refer to plan documents to verify coverage
    • HRSA Requirement
    STERILIZATION:
    Tubal ligation

    58600-58605, 58611, 58670, 58671

    Facility charges for surgery/treatment room, supplies, anesthesia (00851, 00952), lab, medication

    Z30.2, Z98.51

    • Women only
    • Refer to plan documents to verify coverage
    • HRSA Requirement
    TUBERCULOSIS TESTING 86580*

    Z00.00-Z00.01, Z00.110-Z00.3, Z01.411, Z01.419,  Z11.1,  Z76.1-Z76.2

    • Children and adults at high risk
    • HRSA via Bright Futures recommends to age 21
    Service HCPCS/CPT codes Required ICD-10
    diagnosis code
    Guideline/source

    WELL PHYSICAL EXAM:
    Also see Well-child visit information and forms

    Includes age- and gender- appropriate counseling & screening for:

    • Blood pressure
    • Chemoprevention for high risk of breast cancer
    • Contraception methods
    • Dietary counseling
    • Dyslipedemia risk factors
    • Height, weight, Body mass index
    • Intimate partner violence
    • Lead exposure risk assessment
    • Medical history
    • Menopause
    • Obesity
    • Oral health risk (children)
    • Rectal exam of prostate
    • Pelvic & breast exam
    • Sexually Transmitted Infection counseling
    • Vision screening (bundled with E&M service, codes 99172-99173 not separately payable)
    Use age appropriate code 99460 - 99463 99381 - 99397 Not specified
    • Newborn: 3-5 days post discharge
    • 0-2 years: 2, 4, 6, 9, 12, 15, 18 & 24 months
    • 3-6 years: 30 months and then yearly
    • 7-10 years: 1-2 years
    • 11-18 years: yearly
    • Age 19-21 years: 1-3 years
    • Age 22-64 years: 1-3 years
    • Age 65+: yearly
    • USPSTF Rating: B
    WELL PHYSICAL EXAM:
    Ambulatory blood pressure monitoring (ABPM)
    93784-93790 R03.0, I10
    • Confirmation of hypertension using ABPM
    • HRSA Rating: A
    WELL PHYSICAL EXAM:
    Intensive cardiovascular disease counseling
    G0446    

    WELL PHYSICAL EXAM:
    Preventive medicine assessment and risk reduction counseling

    99401-99404, 99411, 99412 Not specified
    WELL PHYSICAL EXAM:
    Depression screening
    96127 Not specified
    WELL PHYSICAL EXAM:
    Health risk assessment
    96160, 96161 Not specified
    WELL PHYSICAL EXAM:
    Alcohol misuse screening and counseling
    99408, 99409
    Not specified
    • Age 11 through adult
    • USPSTF Rating: B
    WELL PHYSICAL EXAM:
    Behavioral counseling for obesity
    G0447    
    WELL PHYSICAL EXAM:
    Smoking and tobacco cessation
    99406, 99407 Not specified USPSTF Rating: A
    WELL PHYSICAL EXAM:
    Vision screening
    99172 - 99173
    Bundled with E&M service
    Not specified
    • Age 3, 4, 5, 6, 8, 10, 12, 15, 18 years
    • USPSTF Rating: B
    Service HCPCS/CPT codes Required ICD-10
    diagnosis code
    Guideline/source
    VACCINATIONS Go to the Vaccines chart for up-to-date coding and coverage information
    VENIPUNCTURE 36415*, 36416* Use the code that qualifies the specific blood test as preventive.