Policy

State mandates and their clarifications do not automatically apply to self-funded groups, but may be included or excluded at the option of the group; therefore, individual group 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), 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
Screenings
- Abdominal Aortic Aneurysm (AAA) 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
- Lipid Disorder Screening
- Lung Cancer Screening
- Syphilis Screening
- Unhealthy Alcohol Use Screening and Behavioral Counseling Interventions
Therapy and Counseling
- Services Included as part of the comprehensive preventive exam
  - Behavioral Counseling for Skin Cancer Prevention
  - High Blood Pressure Screening (Office-based)
  - Obesity Screening
  - Unhealthy Drug Use Screening
- 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
- Tobacco cessation medication
Miscellaneous
- Routine Vaccines
- Prolonged Preventive Services

FEMALE PREVENTIVE SERVICES (ATTACHMENT B)

Visits
- Postpartum Care Visits
- Prenatal Care Visits
- Well-woman visits
Screenings
- Sexually Transmitted Infections Screenings
  - Chlamydia Screening
  - Gonorrhea Screening
  - 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
- Other Preventive Screenings
  - Anxiety Screening
  - Hepatitis B Virus Screening
  - Human Papilloma Virus (HPV) Screening
  - Osteoporosis (Bone Mineral Density) Screening
Therapy and Counseling
- Comprehensive Preventive Evaluation and Management Services
  - 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 Violence Screening
  - Urinary Incontinence Screening
  - Counseling for the Prevention of Obesity
- 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 Contraceptive
- Breastfeeding Support/Counseling and Supplies
- Prolonged Preventive Services

PEDIATRIC PREVENTIVE SERVCES (ATTACHMENT C)

Visits
- Pediatric Prenatal Exams
- Preventive Exams
Screenings
- Alcohol Use/Misuse Screening and Behavioral Counseling Intervention
- Anxiety Screening
- Autism and Developmental Screening
- Behavioral/Social/Emotional Screening
- Bilirubin Screening
- Chlamydia Screening
- Depression and Suicide Risk Screening
- Dyslipidemia Screening
- Gonorrhea Screening
- Hearing Screening for Newborns
- Hearing Screening (all children 29 days or older)
- Hepatitis B Virus Screening
- Human Immunodeficiency Virus (HIV) Screening
- Iron Deficiency Anemia Screening
- Lead Poisoning Screening
- Newborn Screening Panel
- Syphilis Screening
- Vision Screening
Additional Screening Services and Counseling
- Behavioral Counseling for Prevention of Sexually Transmitted Infections
- Nutritional Counseling for Weight Management
- Obesity Screening and Behavioral Counseling
- Recommended Services Included as Part of the Comprehensive Preventive Evaluation and Management Exam or Newborn Care
  - Behavioral Counseling for Skin Cancer Prevention
  - Blood Pressure Screening
  - Congenital Heart Defect Screening
  - Counseling and Education Provided by Healthcare Providers to Prevent Initiation of Tobacco Use
  - Developmental Surveillance
  - Obesity Screening
  - Risk Assessment of Sudden Cardiac Arrest and Sudden Cardiac Death
Medication
- Fluoride
- Prophylactic Ocular Topical Medication for Gonorrhea
Miscellaneous
- Fluoride Varnish Application
- Hemoglobin/Hematocrit Testing
- Routine Vaccines
- Prolonged Preventive Services
- Tuberculosis Testing

TRANSGENDER PREVENTIVE SERVICES

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

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: http://www.cdc.gov/vaccines/acip/index.html. Accessed July 20, 2023.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 July 20, 2023.Recommended Preventive Services. HealthCare.gov. Available at: https://www.healthcare.gov/what-are-my-preventive-care-benefits/. Accessed July 20, 2023.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 July 20, 2023.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 July 20, 2023.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 July 20, 2023.US Preventive Services Task Force. Available at: http://www.uspreventiveservicestaskforce.org/. Accessed July 20, 2023.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 July 20, 2023.Women's Recommendations. Women's Preventive Services Initiative. Available at: https://www.womenspreventivehealth.org/recommendations/. Accessed July 20, 2023.

Coding

CPT Procedure Code Number(s)

See Attachments A, B, and C.

ICD - 10 Procedure Code Number(s)

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)

Coding and Billing Requirements

Policy History

Revisions From 00.06.02aq:

04/01/2024

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 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

Routine 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:

10/01/2022

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 10/01/2022.

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)
K1005

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:

01/01/2022

This 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, the policy in Notification has been updated to revise CPT code narratives for the following codes: 99211, 11981

Revisions From 00.06.02ag:

10/01/2021

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 10/01/2021.

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:

07/01/2020

Attachment 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:

01/02/2019

This 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:

01/01/2019

This 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:

10/01/2018

The 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:

07/01/2018

No 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.

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