Coverage Policy Manual
Policy #: 2011066
Category: PPACA Preventive
Initiated: October 2011
Last Review: March 2014
  PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: OVERVIEW

Description:
PREVENTIVE CARE SERVICES UPDATE
Non-grandfathered/PPACA Wellness Summary
August 2012
 
 
Over the last several months we have had calls and questions on the differences between the pre PPACA wellness benefits and the PPACA wellness benefits for non-grandfathered health plans. We hope that the following Preventive Care Services Summary in this Provider News will help providers have a clearer understanding of the preventive services covered; these of course are subject to change. The preventive services component of the law was a requirement that all “non-grandfathered” health insurance plans are required to cover those preventive medicine services given an “A” or “B” recommendation by the U.S. Preventive Services Task Force (USPSTF). ABCBS has studied these recommendations and has developed a coverage policy on each of these preventive medicine services; please refer to www.arkbluecross.com or www.heathadvantage-hmo.com .
 
In order to comply with the new health care reform law (PPACA or the Patient Protection and Affordability Act), Women’s Preventive Services will be added to many health plans. On August 1, 2012, the change will be made to certain employer-sponsored health insurance plans. The change will take place on January 1, 2013 for certain individual health plans.
 
We encourage each physician and other providers of preventive services to become familiar with the USPSTF, Bright Futures, and Women’s Health Initiative recommendations and ABCBS coverage policies. Most of the inquiries we have received are on lab (urinalysis) and other services such as chest x-rays, electrocardiograms, breathing capacity tests, catheter for hysterography, vitamins, B-12 injections, cardiovascular stress tests, CT for bone density, CT for Head/Brain, Removing Ear Wax, Consultations, etc., that are not included in the USPSTF, Bright Futures, or Women’s Health Initiative recommendations for screening, and are not part of ABCBS coverage policy for non-grandfathered/PPACA Preventive Services. Claims for these services, if billed for screening, therefore would be provider write-offs as not meeting Primary Coverage Criteria or Not Medically Necessary, and are not member liability if billed with a preventive diagnosis unless the ordering provider has obtained from the member a signed  waiver specifically stating why the requested service would not be covered.
 
Summary of Arkansas Blue Cross Blue Shield and Health Advantage Coverage Polices
The Federal Patient Protection and Preventive Care Act (PPACA) was passed by Congress and signed into law by the President in March 2010. The preventive services component of the law became effective September 23, 2010. A component of the law was a requirement that all “non-grandfathered” health insurance plans are required to cover those preventive medicine services given an “A” or “B” recommendation by the U.S. Preventive Services Task Force (USPSTF).
Plans are not required to provide coverage for the preventive services if they are delivered by out-of-network providers.
 
Task Force recommendations are graded on a five-point scale (A-E), reflecting the strength of evidence in support of the intervention. Grade A: There is good evidence to support the recommendation that the condition be specifically considered in a periodic health examination. Grade B: There is fair evidence to support the recommendation that the condition be specifically considered in a periodic health examination. Grade C: There is insufficient evidence to recommend for or against the inclusion of the condition in a periodic health examination, but recommendations may be made on other grounds. Grade D: There is fair evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination. Grade E: There is good evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.
 
Those preventive medicine services listed as Grade A & B recommendations are covered without cost sharing (i.e., deductible, co-insurance, or co-pay) by Health Plans for appropriate preventive care services provided by an in-network provider. If the primary purpose for the office visit is for other than Grade A or B USPSTF preventive care services, deductible, co-insurance, or copay may be applied.
 
Services are typically included as part of a normal wellness visit; the appropriate office visit code should be used. Evaluation and Management codes for preventive services 99381-99397 will always be considered preventive. CPT Codes 99401-99404, when used to designate a preventive service, must have the applicable wellness/preventive diagnosis code as the primary reason for the visit.
 
Note: (99401-99404 are considered components of 99386-99387 if billed on the same date-of-service.)
 
When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’.
 
The correct coding as listed for both ICD-9 and CPT or HCPCS codes in this summary is also required along with Modifier 33. CPT Codes Copyright © 2011American Medical Association.
 
Summary of Women’s Preventive Services
Effective August 1, 2012, for certain employer-sponsored health insurance plans. The change will take place on January 1, 2013 for certain individual health plans.
 
· Well-woman visits: Annual well-woman preventive care visit for adult women to obtain the
recommended preventive services, and additional visits if women and their doctors determine they are necessary.
 
· Gestational diabetes screening: For women 24 to 28 weeks pregnant, and those at high risk of developing gestational diabetes.
 
· HPV DNA testing: Women who are 30 years of age or older will have access to high-risk human papillomavirus (HPV) DNA testing every three years, regardless of pap smear results.
 
· STI counseling, and HIV screening and counseling: Sexually active women will have access to annual counseling on HIV and sexually transmitted infections (STIs).
 
· Contraception and contraception counseling: Coverage of prescription contraceptives on the drug list (brand contraceptives may have a copayment if a generic is available without a copayment), sterilization procedures and patient education and counseling. Plan B (morning-after pill) when prescribed for members under 18 will be covered. Any drugs used to cause abortion (e.g. RU 486) are not covered. Over-the-counter birth control methods, even if prescribed by a doctor, are not covered.
 
· Breastfeeding support, supplies and counseling: Pregnant and postpartum women will have coverage for lactation counseling from applicable health care providers. Manual breast pumps are covered; electric breast pumps and supplies are not covered. NOTE: Pregnancy services including prenatal, delivery and postnatal care subject to member copayments, deductibles and coinsurance.
· Domestic violence screening: Screening and counseling for interpersonal and domestic violence will be covered for all women.
 
Subject to Change as Regulations and Further Clarifications are received, please refer to
additional clarifications at the end of this article.
 
For Self-funded plans with SPD language
Certain self-funded plans may have a different list of preventive care benefits. Please refer to the enrollee’s plan specific SPD for coverage. Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants.
 
Note: Please encourage your patients to update their personal Health Record with information gathered during a preventive visit.
 
Note: The cost of drugs, medications, equipment, vitamins or supplements that are recommended or prescribed for preventive measures are generally not covered as a preventive care benefit. Examples include, but are not limited to:
 
a. Aspirin for any indication, including but not limited to, aspirin for prevention of cardiovascular disease.
b. Supplements, including but not limited to, oral fluoride supplementation, and folic acid supplementation.
c. Tobacco cessation products or medications.
d. Condoms, diaphragms, sponges, spermicides, etc.
e. Electric Breast Pumps
 

Policy/
Coverage:
ABDOMINAL AORTIC ANEURYSM, SCREENING (Coverage Policy 2011011)
USPSTF Recommendation
The USPSTF recommends one-time screening for abdominal aortic aneurysm (AAA) screening for men ages 65 - 75 who have ever smoked.  (Grade B)
CPT/HCPCS Codes:
G0389
ICD-9 Codes
V15.82 - Personal history of tobacco use, presenting hazards to health
V81.2 – Other and unspecified cardiovascular conditions
 
ALCOHOL MISUSE; COUNSELING AND/OR SCREENING (Coverage Policy 2011012)
USPSTF Recommendation
The USPSTF recommends screening and behavioral counseling interventions to reduce alcohol misuse by adults 18 years or older, including pregnant women, in primary care settings. (Grade B)
 
CPT/HCPCS Codes
CPT 99408
CPT 99409
HCPCS G0442
HCPCS G0443
ICD-9 Codes
305.00-.305.03 Nondependent alcohol abuse
V79.1 Screening for alcoholism
 
ALCOHOL AND DRUG USE SCREENING FOR ADOLESCENTS BEGINNING AT AGE 11-18 (Coverage Policy 2011012)
HRSA (Bright Futures) Recommendation
Bright Futures recommends initiating questioning regarding alcohol or drug use and if positive, to follow with an alcohol or drug screening tool.
CPT/HCPCS Codes
CPT 99408
CPT 99409
HCPCS G0442
HCPCS G0443
(These codes are recommended by the AAP [Coding for Pediatric Preventive Care, 2011])
ICD-9 Codes
305.00-.305.03 Nondependent alcohol abuse
V79.1 Screening for alcoholism 5
 
ANEMIA, SCREENING IN INFANTS, CHILDREN & ADOLESCENTS (Coverage Policy 2012036)
HRSA (Bright Futures) Recommendations
Hemoglobin & hematocrit should be screened for at the 4-month well-child visit in children who are preterm or who are low birth weight infants, and those not on iron-fortified formula.
 
Hemoglobin & hematocrit should be screened for routinely at the 12 month well-child visit.
 
Hemoglobin & hematocrit should be screened selectively for children who are positive for risk screening questions at the 3 – 21 year visits.
 
CPT/HCPCS Codes
CPT 85014
CPT 85018
(These codes are recommended by the AAP (Coding for Pediatric Preventive Care, 2011])
ICD-9 Codes
V78.0 – Special screening, iron deficiency anemia
 
ASPIRIN TO PREVENT CARDIOVASCULAR DISEASE IN ADULTS (Coverage Policy 2011013)
USPSTF Recommendations
 
The USPSTF recommends the use of aspirin for men age 45 to 79 years when the potential benefit due to a reduction in myocardial infarctions outweighs the potential harm due to an increase in gastrointestinal hemorrhage. (Grade A)
 
The USPSTF recommends the use of aspirin for women age 55 to 79 years when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage. (Grade A)
 
CPT/HCPCS Codes
CPT 99386-99387
CPT 99396-99397
CPT 99401
CPT 99402
CPT 99403*
CPT 99404*
*CPT 99403 and CPT 99404 require review of records.
(CPT 99401-99404 are considered components of 99386-99387 if billed on the same date-of-service [CPT-4 coding instructions])
ICD-9 Codes
V70.0 - General medical exam
V70.9 - Unspecified general medical exam
 
AUTISM, SCREENING (Coverage Policy 2012045)
HRSA (Bright Futures) Recommendation
Provide the autism specific screening test at the 18 month well child visit.
CPT/HCPCS Codes
CPT 96110
(This code is recommended by the AAP Coding for Pediatric Preventive Care, 2011)
HCPCS G0451
ICD-9 Codes
V20.2 - Routine infant or child health check, for a child over 28 days old.
V79.3 - Special screening for developmental handicaps in early childhood screen), with interpretation and report
 
BACTERIURIA, SCREENING IN PREGNANT WOMEN (Coverage Policy 2011020)
USPSTF Recommendation
The USPSTF recommends screening for asymptomatic bacteriuria with urine culture for pregnant women at 12 to 16 weeks gestation or at the first prenatal visit, if later. (Grade A)
CPT/HCPCS Codes
CPT 87081
CPT 87084
CPT 87086
CPT 87088
ICD-9 Codes
V22.0 – V22.2 - Prenatal Visits
V23.0 – V23.9 - Prenatal visits for patients with high risk pregnancies
 
BICYCLE HELMET USE FOR CHILDREN & ADOLESCENTS, COUNSELING FOR HRSA (Bright Futures) (Coverage Policy 2012044)
Give parents who do not require their children to use a helmet extensive information about the risks of bicycle –related head injuries, including the TIPP [AAP Injury Prevention Program] sheets and details of state or local legislation or regulations. Whenever available, provide discount coupons for approved helmets. Children who answer that they do not use a bicycle helmet should be given information appropriate to their age and cognitive level on the need for helmets.
(Performing Preventive Services: A Bright Futures Handbook)
CPT/HCPCS Codes
CPT 99382-99385
CPT 99392-99395
CPT 99401
(This code is recommended by the AAP (Coding for Pediatric Preventive Care, 2011])
(CPT 99401 is considered a component of 99382-99395 if billed on the same date-of-service [CPT-4 coding instructions])
ICD-9 Codes
V65.43 – Counseling on injury prevention
V20.2 – Routine infant and child health check
V70.0 - General medical exam
V70.9 - Unspecified general medical exam
 
BRCA TESTING, GENETIC COUNSELING AND EVALUATION (Coverage Policy 2011016)
USPSTF RECOMMENDATION
The USPSTF recommends that women whose family history is associated with an increased risk for deleterious mutations in BRCA1 or BRCA2 genes be referred for genetic counseling and evaluation for BRCA testing. (Grade B)
CPT/HCPCS Codes:
CPT 96040,
CPT 99401
CPT 99402
CPT 99403*
CPT 99404*
CPT 81211**
CPT 81212**
CPT 81213**
CPT 81214**
CPT 81215**
CPT 81216**
CPT 81217**
HCPCS S0265
*CPT 99403 and CPT 99404 require review of records.
(CPT 99401-99404 are considered components of 99386-99387 if billed on the same date-of-service [CPT-4 coding instructions])
**Coverage of these genetic testing codes will be effective May 1, 2013.
ICD9 Codes:
V16.3 –Family history of breast cancer
V16.41 – Family history of ovarian cancer
V26.33 – Genetic counseling
 
BREAST CANCER, PREVENTIVE MEDICATION (Coverage Policy 2011017)
USPSTF Recommendation
The USPSTF recommends that clinicians discuss chemoprevention with women at high risk for breast cancer and at low risk for adverse effects of chemoprevention. Clinicians should inform patients of the potential benefits and harms of chemoprevention. (Grade B)
CPT/HCPCS Codes
CPT 99385-99387
CPT 99395-99397
CPT 99401
CPT 99402
CPT 99403*
CPT 99404*
*CPT 99403 and CPT 99404 require review of records.
(CPT 99401-99404 are considered components of 99386-99387 if billed on the same date-of-service
[CPT-4 coding instructions])
ICD-9 Codes
217 - Benign neoplasm of breast
610.8 - Other benign mammary dysplasia
V16.3 - Family history of breast cancer
V84.01 - Genetic susceptibility to breast cancer
 
BREAST CANCER, SCREENING (MAMMOGRAPHY) (Coverage Policy 2011018)
USPSTF Recommendation
The USPSTF currently recommends biennial screening mammography for women with or without clinical breast examination, every 1-2 years for women aged 40 and older. (Grade B)
CPT/HCPCS Codes
CPT 77051
CPT 77052
CPT 77055
CPT 77056
CPT 77057
HCPCS G0202
HCPCS G0204
HCPCS G0206
ICD-9 Codes
V76.11 - Screening mammogram for high risk patient
V76.12 – Other screening mammogram
 
BREASTFEEDING, COUNSELING (Coverage Policy 2011019)
USPSTF Recommendation
The USPSTF recommends interventions during pregnancy and after birth to promote and support breastfeeding. (Grade B)
CPT/HCPCS Codes
CPT 99401
CPT 99402
CPT 99403*
CPT 99404*
HCPCS E0602
HCPCS A4281
HCPCS A4282
HCPCS A4283
HCPCS A4284
HCPCS A4285
HCPCS A4286
*CPT 99403 and CPT 99404 require review of records.
ICD-9 Codes
V24.1 – Postpartum care and examination of lactating mothers.
 
CARDIOMETABOLIC RISKS OF OBESITY IN CHILDREN AND ADOLESCENTS, COUNSELING (Coverage Policy 2012047)
HRSA (Bright Futures) Recommendation
Although Bright Futures does not include screening recommendations for this syndrome, the American Academy of Pediatrics (AAP) has issued a recent policy statement regarding lipid screening and cardiovascular health in childhood, which includes blood pressure assessment. Anticipatory guidance to help children maintain normal blood lipids and blood pressure—2 key components involved in metabolic syndrome—is a crucial part of preventive services for children and adolescents.
CPT Codes
CPT 99382
CPT 99383
CPT 99384
CPT 99385
CPT 99392
CPT 99393
CPT 99394
CPT 99395
ICD-9 Codes
V20.2
V70.0
V70.9
 
CERVICAL CANCER, SCREENING (Coverage Policy 2011021)
USPSTF Recommendation
The USPSTF recommends screening for cervical cancer in women ages 21 to 65 years with cytology (Pap smear) every 3 years or, for women ages 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years. (Grade A)
HRSA (Bright Futures) Recommendation
Bright Futures recommends screening for cervical dysplasia with Pap smear within 3 years of onset of sexual activity.
CPT/HCPCS Codes
CPT 88141-88143
CPT 88147-88148
CPT 88150, 88152-88154
CPT 88164-88167
CPT 88174-88175
HCPCS G0101
HCPCS G0123-G0124
HCPCS G0141
HCPCS G0143-G0145
HCPCS G0147-G0148
P3000-P3001
Q0091
S0610
S0612
ICD-9 Codes
V72.31 - Routine gynecological examination
V72.32 - Encounter for Papanicolaou cervical smear to confirm findings of recent normal smear following initial abnormal smear
V76.2 – Special screening for malignant neoplasm of the cervix
 
CHLAMYDIA INFECTION, SCREENING IN WOMEN & ADOLESCENTS (Coverage Policy 2011022)
USPSTF Recommendation
The USPSTF recommends screening for chlamydial infection for all sexually active non-pregnant young women aged 24 and younger and for older non-pregnant women who are at increased risk. (Grade A)
 
The USPSTF recommends screening for chlamydial infection for all pregnant women age 24 and younger and for older pregnant women who are at increased risk. (Grade B)
 
HRSA (Bright Futures) Recommendation
Screen sexually active adolescents for chlamydia using tests appropriate to the patient population and clinical setting.
CPT/HCPCS Codes:
CPT 87270
CPT 87320
CPT 87490
CPT 87491
CPT 87800
CPT 87801
CPT 87810
ICD-9 Codes
V22.0 – V22.2 - Prenatal Visits
V23.0 – V23.9 - Prenatal visits for patients with high risk pregnancies
V69.2 - High risk sexual behavior
V73.88 - Special screening examination for other specified chlamydial diseases
V73.98 - Special screening examination for unspecified chlamydial disease
V74.5 - Special screening exam for venereal disease
 
COLORECTAL CANCER, SCREENING (Coverage Policy 2011045)
USPSTF Recommendation
The USPSTF recommends screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy, in adults, beginning at age 50 years and continuing until age 75 years.
 
The risks and benefits of these screening methods vary. (Grade A)
CPT/HCPCS Codes:
Use of the PT modifier with specific surgical codes will help identify the procedure as preventive; refer to coverage policy for coverage of polyp removal during a preventive service.
CPT 00810
CPT 45330
CPT 45331
CPT 45333
CPT 45338
CPT 45339
CPT 45378
CPT 45380
CPT 45381
CPT 45383
CPT 45384
CPT 45385
CPT 82270
CPT 82274
CPT 88305
HCPCS G0104
HCPCS G0105
HCPCS G0121
HCPCS G0328
ICD-9 Codes:
V76.41 Screening for malignant neoplasm of the rectum
V76.51 Special screening for malignant neoplasms, colon
 
CONGENITAL/INHERITED METABOLIC DISORDERS & HEMOGLOBINOPATHIES (Coverage Policy 2012040)
HRSA (Bright Futures) Recommendation
Conduct screening as required by the state. (Arkansas statute requires newborn screening for metabolic (inborn errors of metabolism) and hemoglobinopathies); the tests are usually done prior to discharge from the hospital following birth of the infant).
CPT/HCPCS Codes
S3620
ICD9 Codes
V77.0 – Special screening for thyroid disorders
V77.3 – Special screening for phenylketonuria
V77.4 – Special screening for galactosemia
V77.7 – Special screening for other inborn errors of metabolism
V78.2 – Special screening for sickle cell disease
V78.3 – Special screening for other hemoglobinopathies
 
CONTRACEPTIVE USE & COUNSELING (Coverage Policy 2012035)
HRSA (Women’s Health Initiative) Recommendation (Effective Aug 2012)
Women will have access to all Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling. These recommendations do not include abortifacient drugs.
 
OTC products (condoms, sponges, diaphragms, spermicides, etc.) are not covered. There is a $0 copayment for all generic prescription contraceptives. If there is no generic in the class/subclass, then brand contraceptive is at $0 copayment. Emergency contraceptives for members who are less than 18 years old for Plan B and those who are less than 17 years old for Plan B One-Step if they present a prescription for coverage. Note: Those patients at or above the ages previously mentioned do not need a prescription to get access to emergency contraceptives as they are available OTC in these age groups and are not covered.
 
CPT & HCPCS CODES
CPT 00851
CPT 11976
CPT 11980
CPT 11981
CPT 11982
CPT 11983
CPT 57170
CPT 58300
CPT 58301
CPT 58565
CPT 58600
CPT 58605
CPT +58611
CPT 58615
CPT 58670
CPT 58671
CPT 64435
CPT 74740
CPT 96372
CPT 99384
CPT 99385
CPT 99386
CPT 99394
CPT 99395
CPT 99396
HCPCS G0438
HCPCS G0439
HCPCS S4981
HCPCS S4989
HCPCS S4993
HCPCS A4261
HCPCS A4264
HCPCS A4266
HCPCS J1050
HCPCS J1055
HCPCS J7300
HCPCS J7301
HCPCS J7302
HCPCS J7303
HCPCS J7304
HCPCS J7306
HCPCS J7307
HCPCS Q0090
 
ICD-9 CODES
V25.01 – Prescription of oral contraceptives
V25.02 – Initiation of other contraceptive measures
V25.03 – Encounter for emergency contraceptive counseling and prescription
V25.04 – Counseling and instruction in natural family planning to avoid pregnancy
V25.09 – Encounter for contraceptive management, general counseling and advice; other
V25.11 – Encounter for insertion of intrauterine contraceptive device
V25.12 - Encounter for removal of intrauterine contraceptive device
V25.13 – Encounter for removal and reinsertion of intrauterine contraceptive device
V25.2 - Sterilization
V25.40 - Conceptive surveillance, unspecified
V25.41 – Surveillance of previously prescribed contraceptive methods for contraceptive pill
V25.42 – Surveillance of previously prescribed contraceptive methods for intrauterine contraceptive device
V25.43 – Surveillance of previously prescribed contraceptive methods for implantable subdermal contraceptive
V25.49 – Surveillance of previously prescribed contraceptive methods for other contraceptive methods
V25.5 – Encounter for insertion of implantable subdermal contraceptive
 
DENTAL CARIES IN PRESCHOOL CHILDREN (Coverage Policy 2011029)
USPSTF Recommendation
The USPSTF recommends that primary care clinicians prescribe oral fluoride supplementation at currently recommended doses to preschool children older than 6 months of age whose primary water source is deficient in fluoride. (Grade B)
HRSA (Bright Futures) Recommendation
Oral fluoride supplementation if the primary water source is deficient in fluoride from age 1 to 6.
CPT HCPCS Codes:
CPT 99381-99383
CPT 99391-99393
ICD-9 Codes
V20.2 – Routine infant or child health check
V07.31 – Need for prophylactic fluoride administration
 
DEPRESSION, SCREENING IN ADULTS (Coverage Policy 2011043)
USPSTF Recommendation
The USPSTF recommends screening adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up. (Grade B)
 
CPT/HCPCS Codes:
CPT 99385-99387
CPT 99395-99397
HCPCS G0444
ICD-9 Code
V79.0 Screening for depression
 
DEPRESSION, SCREENING IN ADOLESCENTS (Coverage Policy 2011044)
USPSTF Recommendation
The USPSTF recommends screening of adolescents (12-18 years of age) for major depressive disorder (MDD) when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal), and follow-up. (Grade B)
CPT HCPCS Codes:
CPT 99384-99385
CPT 99394-99395
HCPCS G0444
ICD-9 Code
V79.0 Screening for depression
 
DEVELOPMENTAL SCREENING (Coverage Policy 2012048)
HRSA (Bright Futures) Recommendation
Begin structured developmental screening at the 18 month well child visit, with repeat evaluation at 2½ years.
CPT/HCPCS Codes
CPT 96110
(This code is recommended by the AAP (Coding for Pediatric Preventive Care, 2011])
HCPCS G0451
ICD-9 Codes
V79.3 – Special screening for developmental handicaps in early childhood
V79.8 – Special screening for other specified mental disorders and handicaps
 
DIABETES MELLITUS, TYPE 2, SCREENING IN ADULTS (Coverage Policy 2011026)
USPSTF Recommendation
The USPSTF recommends screening for Type 2 Diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg. (Grade B)
CPT/HCPCS Codes
CPT 82947
CPT 82950
CPT 83036
ICD-9 Codes:
V77.1 – screening for diabetes mellitus
 
DIABETES MELLITUS, SCREENING IN PREGNANT WOMEN 24 & 28 WEEKS GESTATION AND AT FIRST PRENATAL VISIT FOR PREGNANT WOMEN IDENTIFIED AS HIGH RISK FOR DIABETES (Coverage Policy 2012032)
HRSA (Women’s Health Initiative) Recommendation (Effective Aug 2012)
The Women’s Health Initiative recommends screening for Diabetes Mellitus in pregnant women 24 and 28 weeks gestation and at first prenatal visit for pregnant women identified as high risk for diabetes.
CPT/HCPCS Codes
CPT 82947
CPT 82950
CPT 83036
ICD-9 Codes:
V22.0-V22.2
V23.0-V23.9
V77.1 – screening for diabetes mellitus
 
FALLS, PREVENTION IN COMMUNITY-DWELLING OLDER ADULTS (Coverage Policy 2012055)
USPSTF Recommendation
The USPSTF recommends exercise or physical therapy and vitamin D supplementation to prevent falls in community-dwelling adults aged 65 years or older who are at increased risk for falls. (Grade B).
CPT/HCPCS Codes
CPT 97001
CPT 97002
CPT97110
CPT 97112
CPT 97116
CPT 97750
HCPCS G0159
HCPCS S9131
ICD-9 Codes
V15.88
  
FOLIC ACID, PREVENTION OF NEURAL TUBE DEFECTS (Coverage Policy 2011041)
USPSTF Recommendation
The USPSTF recommends that all women planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 to 800 µg) (Grade A) of folic acid. Not routinely covered for “all women capable of pregnancy”. (Grade A)
CPT/HCPCS Codes
Information on folic acid is typically provided during an office visit.  
ICD-9 Codes
V65.49 Other specified counseling
 
GONORRHEA, PROPHYLAXIS, NEWBORN OPHTHALMIC (Coverage Policy 2011035)
USPSTF Recommendation
The USPSTF strongly recommends prophylactic ocular topical medication for all newborns against ophthalmia neonatorum. (Grade A)
CPT/HCPCS Code:
CPT 99461
CPT 99381
ICD 9 Code:
V07.8 – Need for other specified prophylactic measure
V20.31 - Health supervision for newborn under 8 days old
V20.32 - health supervision for newborn 8 to 28 days old
 
GONORRHEA, SCREENING (Coverage Policy 2011038)
USPSTF Recommendation
The USPSTF recommends that clinicians screen all sexually active women, including those who are pregnant for gonorrhea infection if they are at increased risk for infection (i.e., if young or have other individual or population. (Grade B)
HRSA (Bright Futures) Recommendation
Screen sexually active adolescents for chlamydia using tests appropriate to the patient population and clinical setting.
CPT/HCPCS Codes:
CPT 87590
CPT 87591
CPT 87800
CPT 87801
CPT 87850
ICD-9 Codes
V69.2 – High risk sexual behavior
V74.5 Special Screening Exam for Venereal Disease
 
HEARING LOSS, SCREENING IN NEWBORNS AND UP TO AGE 21 (Coverage Policy 2011036)
USPSTF Recommendation
The USPSTF recommends screening for hearing loss in all newborn infants. (Grade B)
HRSA (Bright Futures) Recommendation
If not done at birth (e.g., newborn delivered at home or discharged from Neonatal Intensive Care Unit) screening should be completed within the first month of life.
 
After the 4th month, if there are positive responses to risk screening questions, the infant should be referred for diagnostic audiologic assessment.
 
At years 5, 6, and 10, audiometry is recommended, universally. Otherwise, at the 7th through the 21st years if there are positive responses to risk screening questions, audiometry is recommended.
CPT HCPCS Codes:
CPT 92551
CPT 92552
CPT 92558
CPT 92579
CPT 92582
CPT 92586
 
ICD 9 Codes:
V20.2 – Routine infant or child health check
V20.31 – Health supervision for newborn under 8 days old
V20.32 – Health supervision for newborn 8 to 28 days old
V70.0 - General medical examination
V72.19 – Other examination of ears and hearing
 
HEPATITIS B VIRUS INFECTION IN PREGNANCY, SCREENING (Coverage Policy 2011039)
USPSTF Recommendation
The USPSTF strongly recommends screening for hepatitis B virus infection in pregnant women at their first prenatal visit (Grade A)
CPT/HCPCS Codes:
CPT 80055
CPT 87340
ICD-9 Codes
V22.0 – V22.2 - Prenatal Visits
V23.0 – V23.9 - Prenatal visits for patients with high risk pregnancies
V28.9 - Antenatal screening NOS
 
HIGH BLOOD PRESSURE, SCREENING IN ADULTS (Coverage Policy 2011015)
USPSTF Recommendation
The USPSTF recommends screening for high blood pressure in adults aged 18 and older. (Grade A)
CPT/HCPCS Codes
CPT 99385-99387
CPT 99395-99397
ICD-9 Codes
V81.1 - Screening for hypertension
 
HIGH BLOOD PRESSURE, SCREENING IN INFANTS, CHILDREN & ADOLESCENTS (Coverage Policy 2012037)
HRSA (Bright Futures) Recommendation
Infants & children with specific risk factors for high blood pressure should be screened up through age 2½; blood pressure examination is included in the complete physical examination done routinely after 2½.
CPT/HCPCS Codes
CPT 99381-99384
CPT 99391-99394
ICD-9 Codes
V20.2 – Routine infant or child health check
V70.0 – Routine general health examination
V81.1 - Screening for Hypertension
 
HUMAN IMMUNODEFICIENCY VIRUS (HIV), COUNSELING AND SCREENING (Coverage Policy 2011040)
USPSTF Recommendation
The USPSTF strongly recommends that clinicians screen for human immunodeficiency virus (HIV) all adolescents and adults at increased risk for HIV infection. (Grade A)
HRSA (Bright Futures) Recommendation
Sexually active adolescents who are positive on risk questions should be screened for HIV.
HRSA (Women’s Health Initiative) Recommendation (Effective Aug 2012)
The Women’s Health Initiative strongly recommends that clinicians counsel and screen for human immunodeficiency virus (HIV), annually.
Screening will be allowed up to 3 times per year
CPT/HCPCS Codes:
CPT 86689
CPT 86701
CPT 86703
CPT 87389
CPT 87390
CPT 87535
CPT 99401
CPT 99402
CPT 99403*
CPT 99404*
*CPT 99403 and CPT 99404 require review of records.
HCPCS G0432
HCPCS G0433
HCPCS G0435
HCPCS S3645
ICD-9 Codes
V01.79 –Contact or exposure to other viral diseases
V22.0 – V22.2 - Prenatal Visits
V23.0 – V23.9 - Prenatal visits for patients with high risk pregnancies
V65.44 – Human immunodeficiency virus counseling
V69.2 - Problems related to high risk sexual behavior
V69.8 - Other problems related to lifestyle
V73.89 Special screening examination for other specified viral diseases
 
HUMAN PAPILLOMA VIRUS TESTING (Coverage Policy 2012034)
HRSA (Women’s Health Initiative) Recommendation (Effective Aug 2012)
The Women’s Health Initiative recommends HPV testing every 3 years beginning at age 30 for sexually active women.
CPT/HCPCS Codes
CPT 87621
ICD 9 Codes
V72.31 – Routine gynecological examination
V73.81 – Special screening examination, human papillomavirus [HPV]
V76.2 – Screening for malignant neoplasm of the cervix
 
HYPOTHYROIDISM, SCREENING IN NEWBORNS (Coverage Policy 2011023)
USPSTF Recommendation
The USPSTF recommends screening for congenital hypothyroidism in newborns. (Grade A)
HRSA (Bright Futures) Recommendation
Conduct screening as required by the state. (Arkansas statute requires newborn screening for hypothyroidism; this test is usually done prior to discharge from the hospital following birth of the infant).
CPT/HCPCS Codes
CPT 84436 – Thyroxine; Total
CPT 84437 – Thyroxine; requiring elution (e.g..neonatal)
CPT 84439 – Thyroxine; free
CPT 84443 – Thyroid stimulating hormone (TSH)
ICD-9 Codes:
V77.0 - Screening for thyroid disorder
 
INTIMATE PARTNER VIOLENCE, SCREENING/COUNSELING OF WOMEN, ANNUALLY (Coverage Policy 2012021)
HRSA (Women’s Health Initiative) Recommendation (Effective Aug 2012)
The Women’s Health Initiative recommends screening/counseling for intimate partner violence annually.
CPT/HCPCS Codes
CPT 99385-99387 - Initial comprehensive preventive medicine evaluation and management of an individual
CPT 99395-99397 - Periodic comprehensive preventive medicine reevaluation and management of an individual
CPT 99401 - Preventive medicine counseling; 15 minutes
CPT 99402 – Preventive medicine counseling; 30 minutes
CPT 99403* – Preventive medicine counseling; 45 minutes
CPT 99404* – Preventive medicine counseling; 60 minutes
*CPT 99403 and CPT 99404 require review of records.
(CPT 99401-99404 are considered components of 99381-99397 if billed on the same date-of-service [CPT-4 coding instructions])
ICD 9 Codes
V61.11 – Counseling for victim of spousal and partner abuse
V70.0 – General medical exam
 
IRON DEFICIENCY AMEMIA SCREENING IN PREGNANT WOMEN (Coverage Policy 2011014)
USPSTF Recommendation
The USPSTF recommends routine screening for iron deficiency anemia in asymptomatic pregnant (Grade B).
CPT/HCPCS Codes:
CPT 80050
CPT 80055
CPT 85013
CPT 85014
CPT 85018
CPT 85025
CPT 85027
HCPCS G0306
HCPCS G0307
ICD-9 Codes
V22.0 – V22.2 - Prenatal Visits
V23.0 – V23.9 - Prenatal visits for patients with high risk pregnancies
 
IRON SUPPLEMENTATION FOR CHILDREN (Coverage Policy 2011042)
USPSTF Recommendation
The USPSTF recommends routine iron supplementation for asymptomatic children aged 6 to 12 months who are at increased risk for iron deficiency anemia. (Grade B)
CPT/HCPCS Codes
No codes
ICD-9 Codes
V20.2 – Routine infant or child health check
 
LEAD SCREENING IN INFANTS CHILDREN AND THROUGH AGE 6 (Coverage Policy 2012038)
HRSA (Bright Futures) Recommendation
Begin screening at the 6-month well-child visit for children who are positive on risk screening questions.  Continue as routine screening for children from high prevalence area or on Medicaid, and screen selectively children from low prevalence areas and not on Medicaid.
CPT/HCPCS Codes
CPT 83655
ICD-9 Codes
V82.5 – Screening for chemical poisoning & other contamination
 
LIPID (CHOLESTEROL), SCREENING (Coverage Policy 2011010)
USPSTF Recommendations
The USPSTF strongly recommends screening men aged 35 and older for lipid disorders. (Grade A)
 
The USPSTF recommends screening men aged 20 to 35 for lipid disorders if they are at increased risk for coronary heart disease. (Grade B)
 
The USPSTF strongly recommends screening women aged 45 and older for lipid disorders if they are at increased risk for coronary heart disease. (Grade A)
 
The USPSTF recommends screening women aged 20 to 45 for lipid disorders if they are at increased risk for coronary heart disease. (Grade B)
 
HRSA (Bright Futures) Recommendation
Begin screening with lipid profile for children who test positive on risk screening questions beginning at age 2. Screening would not be repeated unless the child or adolescent’s risk factors changed. If the risk factors change, screening could be repeated at 4 years, 6 years, 8 years, 10 years, between 11 and 14 years, between 15 and 17years and between 18 and 21 years.
CPT/HCPCS Codes:
CPT 80061
CPT 82465
CPT 83718
ICD-9 Codes:
V77.91 – Screening for lipoid disorders
V70.0 – General medical exam
V70.9 - General medical exam, NOS
V20.2 Routine infant or child health check
 
MEDIA USE BY CHILDREN & ADOLESCENTS, SCREENING & COUNSELING FOR  (Coverage Policy 2012042)
HRSA (BRIGHT FUTURES) Recommendation
Screening:
To screen for media usage, clinicians should ask 2 questions about media use at health supervision visits:
1) How much screen time per day does the child spend?
2) Is there a TV set or Internet connection in the child’s bedroom?
Counseling:
Since they potentially influence numerous aspects of child and adolescent health, the media may represent the most important area of anticipatory guidance in well-child visits. One study has shown that a minute or two of office counseling about media violence and guns could reduce violence exposure for nearly 1 million children per year. Given the sheer number of hours that children spend with media, counseling is imperative.
CPT/HCPCS Codes
CPT 99382
CPT 99383
CPT 99384
CPT 99392
CPT 99393
CPT 99394
ICD-9 Codes
V65.49 – Other specified counseling
V65.40 – Counseling, Not Otherwise Specified
 
NUTRITION (DIETARY) COUNSELING, ADULTS (Coverage Policy 2011034)
USPSTF Recommendation
The USPSTF recommends intensive behavioral dietary counseling for adult patients with hyperlipidemia
and other known risk factors for cardiovascular and diet-related chronic disease. Intensive counseling can
be delivered by primary care clinicians or by referral to other specialists, such as nutritionists or dietitians.
(Grade B)
CPT/HCPCS Codes
CPT 97802 – 97803
CPT 99401
CPT 99402
CPT 99403*
CPT 99404*
HCPCS G0108
CPCS G0109
HCPCS G0270
HCPCS S9140-S9141
HCPCS S9452
HCPCS S9455-S9465
HCPCS S9470
*CPT 99403 and CPT 99404 require review of records.
ICD-9 Codes:
V65.3 – Dietary surveillance and counseling
 
OBESITY IN ADULTS AND CHILDREN 6 YEARS OR OLDER; SCREENING AND COUNSELING (Coverage Policies  2011025 and 2011030)
USPSTF Recommendation (Recommendation changed June 2012)
Effective June 2012:
The USPSTF recommends screening all adults for obesity. Clinicians should offer or refer patients with a body mass index (BMI) of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions.  (Grade B)
 
Prior to June 2012:
The USPSTF recommends that clinicians screen all adult patients and children 6 years or older for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese individuals. For children clinicians should offer then or refer them to comprehensive, intensive behavioral interventions to promote improvement in weight status. (Grade B)
HRSA (Bright Futures – Anticipatory Guidance)
Bright Futures identifies healthy weight promotion as 1 of 2 critical themes within the guidelines.  Recommendations in Bright Futures are consistent with the Prevention and Prevention Plus stages outlined in the Expert Committee Recommendations regarding the Prevention, Assessment, and Treatment of Child Adolescent Overweight and Obesity.  This recommendation applies to children age 6 and above.  
CPT/HCPCS Codes
CPT 99383-99387
CPT 99393-99397
CPT 99401
CPT 99402
CPT 99403*
CPT 99404*
HCPCS G0447
*CPT 99403 and CPT 99404 require review of records
(CPT 99401 – 99404 are considered components of 99381 or 99397 if billed on the same date-of-service [CPT-4 coding instructions])
ICD-9 Codes
V70.0 – General medical exam
V77.8 – Screening for obesity
V20.2 - Routine infant or child health check, for child over 28 days
 
OSTEOPOROSIS SCREENING IN WOMEN (Coverage Policy 2011031)
USPSTF Recommendation
The USPSTF recommends screening for osteoporosis in women age 65 and older, be screened routinely for osteoporosis. The USPSTF recommends that routine screening begin at age 60 for women at increased risk for osteoporotic fractures. (Grade B).
CPT/HCPCS Codes
CPT 77080
ICD-9 Codes
V82.81 Special screening for osteoporosis
 
PHENYLKETONURIA SCREENING IN NEWBORNS (Coverage Policy 2011028)
USPSTF Recommendation
The USPSTF recommends screening for phenylketonuria (PKU) in newborns. (Grade A)
HRSA (Bright Futures) Recommendation
Conduct screening as required by the state. (Arkansas statute requires newborn screening for phenylketonuria; this test is usually done prior to discharge from the hospital following birth of the infant).
CPT/HCPCS Code
CPT 84030
ICD-9 Codes:
V77.3 – Screening for Phenylketonuria (PKU)
 
PREGNANCY, SCREENING, IN SEXUALLY ACTIVE FEMALES WITHOUT CONTRACEPTION, LATE MENSES, OR AMENORRHEA (Coverage Policy 2012041)
HRSA (Bright Futures) Recommendation
The USPSTF recommends screening for pregnancy with urine human chorionic gonadotrophin in sexually active females who do not practice contraception, who have late menses, or amenorrhea, ages 11 to 21.
CPT/HCPCS Codes
CPT 81025
CPT 84703
ICD9 Code
V70.0 - General medical exam
 
PREVENTION OF SKIN CANCER; COUNSELING OF PERSONS 10-24 (Coverage Policy 2012018)
The USPSTF recommends conseling children, adolescents and young adults ages 10-24 years who have fair skin, about minimizing their exposure to ultraviolet radiation to reduce risk for skin cancer (Grade B).  
CPT/HCPCS Codes
CPT 99383-99385
CPT 99393-99395
ICD-9 Codes
V20.2
V70.0
V70.9
 
RH INCOMPATABILITY SCREENING (Coverage Policy 2011027)
USPSTF Recommendations
The USPSTF strongly recommends Rh (D) blood typing and antibody testing for all pregnant women during their first visit for pregnancy-related care.(Grade A)
The USPSTF recommends repeated Rh (D) antibody testing for all unsensitized Rh (D)-negative women at 24-28 weeks' gestation, unless the biological father is known to be Rh (D)-negative. (Grade B)
CPT/HCPCS Codes:
CPT 80055
CPT 86901
ICD-9 Code
V22.0 – V22.2 - Prenatal Visits
V23.0 – V23.9 - Prenatal visits for patients with high risk pregnancies
 
SEXUALLY TRANSMITTED INFECTIONS (STI’s); BEHAVIORAL COUNSELING TO PREVENT (Coverage Policy 2011032)
USPSTF Recommendation
The USPSTF recommends high intensity behavioral counseling to prevent sexually transmitted infections (STI’s) for all sexually active adolescents and for adults at increased risk for STI’s. (Grade B)
CPT/HCPCS Codes
CPT 99401
CPT 99402
CPT 99403*
CPT 99404*
HCPCS G0445
*CPT 99403 and CPT 99404 require review of records.
ICD-9 Codes
V65.44 - Human immunodeficiency virus counseling
V65.45 – Counseling on other sexually transmitted diseases
V69.2 – Problems related to high-risk sexual behavior
 
SEXUALLY TRANSMITTED INFECTIONS (STI’s); COUNSELING AND SCREENING (Coverage Policy 2011032)
HRSA (Women’s Health Initiative) Recommendation (Effective Aug 2012)
The Women’s Health Initiative recommends that clinicians counsel all sexually active women, annually.
CPT/HCPCS Codes
CPT 99401
CPT 99402
CPT 99403*
CPT 99404*
HCPCS G0445
*CPT 99403 and CPT 99404 require review of records.
ICD-9 Codes
V65.44 - Human immunodeficiency virus counseling
V65.45 – Counseling on other sexually transmitted diseases
V69.2 – Problems related to high-risk sexual behavior
 
SKIN CANCER COUSELING FOR PERSONS 10 – 24 YEARS (Coverage Policy 2012018)
USPSTF Recommendation (Effective July 2012)
The USPSTF recommends counseling children, adolescents, and young adults aged 10 to 24 years who have fair skin about minimizing their exposure to ultraviolet radiation to reduce risk for skin cancer.
(Grade B)
CPT/HCPCS Codes
CPT 99383
CPT 99384
CPT 99385
CPT 99393
CPT 99394
CPT 99395
ICD9 Codes
V20.2 – Routine infant or child health check
V70.0 - General Medical Examination
V70.9 - Unspecified general medical examination
 
SICKLE CELL SCREENING DISEASE, NEWBORN SCREENING (Coverage Policy 2011032)
USPSTF Recommendation
The USPSTF recommends screening for sickle cell disease in newborns. (Grade A)
HRSA (Bright Futures) Recommendation
Conduct screening as required by the state. (Arkansas statute requires newborn screening for hemoglobinopathies; this test is usually done prior to discharge from the hospital following birth of the infant).
CPT/HCPCS Codes
CPT 83020
CPT 83021
HCPCS S3620
ICD9 Code
V78.2 – Special screening for sickle cell disease or trait.
 
SYPHILIS, SCREENING (Coverage Policy 2011037)
USPSTF Recommendation
The USPSTF recommends that clinicians screen all persons at increased risk for syphilis infection, and all pregnant women for syphilis infection. (Grade A)
HRSA (Bright Futures) Recommendation
Bright Futures recommends screening for syphilis in all adolescents who are sexually active and positive for high risk.
CPT/HCPCS Codes:
CPT 80055
CPT 86592
CPT 86780
ICD-9 Codes
V22.0 – V22.2 - Prenatal Visits
V23.0 – V23.9 - Prenatal visits for patients with high risk pregnancies
V69.2 Problems related to high risk sexual behavior
V74.5 Screening examination for venereal disease
 
TOBACCO USE, SCREENING, COUNSELING AND INTERVENTIONS (Coverage Policy 2011024)
USPSTF Recommendation
The USPSTF recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products. (Grade A)
 
The USPSTF recommends that clinicians ask all pregnant women about tobacco use and provide augmented, pregnancy-tailored counseling for those who smoke. (Grade A)
 
HRSA (Bright Futures) Recommendation
Bright Futures recommends that health care professionals screen for tobacco use and tobacco smoke exposure, encourage tobacco use cessation, and provide tobacco use cessation strategies and resources at most visits for adolescents ages 11 through 21.
CPT/HCPCS Codes:
CPT 99406
CPT 99407
(Bright Futures recommends these codes when reporting tobacco use by parents)
HCPCS G0436
HCPCS G0437
ICD9 Codes
305.1 – Tobacco dependence
649.01-649.04 – Smoking complicating pregnancy
V15.82 – History of tobacco use
V15.89 – Other specified personal history presenting hazards to health, Other
(Bright Futures recommends these codes when reporting tobacco use by parents)
V22.0 – V22.2 - Prenatal Visits
V23.0 – V23.9 - Prenatal visits for patients with high risk pregnancies
V65.49 – Other specified counseling
 
TUBERCULOSIS, SCREENING (Coverage Policy 2012039)
HRSA (Bright Futures) Recommendation
Begin selective screening for tuberculosis with the tuberculin skin test for infants, children, and adolescents who are at increased risk based on risk screening questions, at the first month well-child visit and continue through adolescence.
CPT/HCPCS Codes
CPT 86580
ICD9 Code
V74.1 – Screening for pulmonary tuberculosis
V01.0 - Contact with or exposure to tuberculosis
 
VISUAL IMPAIRMENT, SCREENING IN CHILDREN (Coverage Policy 2011033)
USPSTF Recommendation
The USPSTF recommends vision screening for all children at least once between the ages of 3 and 5 years, to detect the presence of amblyopia or its risk factors (Grade B)
HRSA (Bright Futures) Recommendation
Selective screening or newborn, infants, and children through age 2, to assess for abnormal funduscopic examination, particularly if premature or other risk conditions.
 
Objective measurement of vision with age-appropriate visual acuity measurement using HOTV, tumbling E tests, Snellen letters, Snellen numbers, or Picture tests such as Allen figures or LEA symbols.
CPT/HCPS Code
CPT 99173
CPT 99174
ICD9 Codes:
V20.2 – Routine infant or child health check
V72.0 – Examination of eyes and vision
V80.2 Special screening for “other eye conditions”, including congenital anomaly of eye
 
WELL-CHILD VISITS, NEWBORN, INFANT, CHILDREN, ADOLESENTS, & AGES 18-21 (Coverage Policy 2012046)
HRSA (Bright Futures) Recommendation
Bright Futures recommends well child visits at birth, first week after birth, at age 1 month, 2 months, 4 months, 6 months, 9 months, 1 year, 15 months, 18 months, 2 years, 2½ years, 3 years, 4 years, 5 years, 6 years, 7 years, 8 years, 9 years, 10 years, between 11-14 years, between 15-17 years, and 18 to 21 years.
 
Coverage for these visits are similar to that required by Arkansas Statute.
CPT/HCPCS
CPT 99381 - 99385
CPT 99391 - 99395
ICD9 Codes
V20.2 – Routine infant or child health check (ages infant through 17)
V20.31 - Health supervision for newborn under 8 days old
V20.32 - health supervision for newborn 8 to 28 days old
V70.0 – Routine general health exam at a health care facility
V65.43 - Counseling on injury prevention
V70.9 - Unspecified general health examination
 
 
WELL WOMAN VISIT FOR ADULT WOMEN (Coverage Policy 2012031)
HRSA (Women’s Health Initiative)
CPT/HCPCS Codes
CPT 59425
CPT 59426
CPT 99385
CPT 99386
CPT 99387
CPT 99395
CPT 99396
CPT 99387
HCPCS G0438
HCPCS G0439
ICD9 Codes
V70.0 – General Medical Examination
 
Other Preventive Services
 
ACIP Immunizations Recommendations
An immunization that does not fall under one of the exclusions in the Certificate of Coverage is
considered covered after all of the following conditions are satisfied: (1) FDA approval; (2) explicit ACIP recommendation published in the Morbidity & Mortality Weekly Report (MMWR) of the Centers for Disease Control and Prevention (CDC). Implementation will typically occur within 60 days after publication in the MMWR.
 
Immunization Administration Codes:
CPT 90460
CPT 90461
CPT 90471
CPT 90472
CPT 90473
CPT 90474
HCPCS G0008
HCPCS G0009
HCPCS G0010
Immunization/Vaccine Codes
CPT 90375 - Rabies immune globulin, (Rig), for intramuscular and/or subcutaneous use
CPT 90376 - Rabies immune globulin, heat treated (Rlg-HT), human, for intramuscular and/or subcutaneous use
CPT 90396- Varicella-zoster immune globulin, human, for intramuscular use; (Appropriate ICD-9 code is V05.4)
CPT 90632 - Hepatitis A vaccine, adult, for intramuscular use; (Appropriate ICD9 code is V05.3)
CPT 90633 - Hepatitis A vaccine, pediatric/adolescent dosage-2 dose schedule, for intramuscular use  (Appropriate ICD( code is V05.3)
CPT 90636 - Hepatitis A and hepatitis B vaccine (HepA-HepB), adult dosage, for intramuscular use  (Appropriate ICD9 code is V05.3)
CPT 90644 - Meningococcal conjugate vaccine, serogroups C & Y and Hemophilus influens B Vaccine, tetanus toxoid conjugate (Hib-MenCY-TT) (4 dose schedule)
CPT 90645 - Hemophilus influenza b vaccine (Hib), HbOC conjugate (4 dose schedule), for intramuscular use  (Appropriate ICD9 code is V03.81)
CPT 90646 - Hemophilus influenza b vaccine (Hib), PRP-D conjugate, for booster use only, intramuscular use  (Appropriate ICD9 code is V03.81)
CPT 90647 - Hemophilus influenza b vaccine (Hib), PRP-OMP conjugate (3 dose schedule), for intramuscular use  (Appropriate ICD9 code is V03.81)
CPT 90648 - Hemophilus influenza b vaccine (Hib), PRP-T conjugate (4 dose schedule), for intramuscular use  (Appropriate ICD9 code is V03.81)
CPT 90649 – Human Papilloma virus (HPV) vaccine, types 6, 11, 16, 18 (quadrivalent), 3 dose schedule, for intramuscular use Note: coverage for 90649 is limited to female adolescents and adults ages 11 – 26. And Male adolescents and adults ages 11—26.  (Males effective July 2010.)
(Appropriate ICD9 code is V04.89))
CPT 90650 – Human Papilloma virus (HPV) vaccine, types 16, 18, bivalent, 3 dose schedule, for intramuscular use Note: coverage for 90650 is limited to females age 11 – 26. (Appropriate ICD9 code is V04.89)
CPT 90655 – Influenza virus vaccine, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use (Appropriate ICD9 code is V04.81)
CPT 90656 – Influenza virus vaccine, split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use (Appropriate ICD9 code is V04.81)
CPT 90657 – Influenza virus vaccine, split virus, when administered to children 6-35 months of age, for intramuscular use (Appropriate ICD9 code is V04.81)
CPT 90658 – Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Appropriate ICD9 code is V04.81)
CPT 90660 – Influenza virus vaccine, live, for intranasal use Note: coverage is limited to ages 2 – 49
(Appropriate ICD9 code is V04.81)
CPT 90662 - Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity.  Adults 65 & Over.  
CPT 90669 – Pneumococcal Vacc
CPT 90670 – Pneumococcal conjugate vaccine, 13 valent, for intramuscular use (Appropriate ICD9 code is V03.82)
CPT 90675 - Rabies Vaccine for intramuscular use. Only for Very Select Persons Who Meet Specific Criteria.
CPT 90680 – Rotavirus vaccine, pentavalent, 3 dose schedule, live, for oral use (Appropriate ICD9 code is V04.89)
CPT 90681 – Rotavirus vaccine, human, attenuated, 2 dose schedule, live, for oral use (Appropriate ICD9 code is V04.89)
90685   Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use (Appropriate ICD9 code is V04.81)
90686   Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to individuals 3 years of age and older, for intramuscular use (Appropriate ICD9 code is V04.81)
90688 Influenza virus vaccine, quadrivalent, split virus, when administered to individuals 3 years of age and older, for intra muscular use. (Appropriate ICD9 code is V04.81)
 
CPT 90690 - Typhoid vaccine, live, oral. Only for Very Select Children 6 years of age & over, Adolescents, or Adults who meet certain criteria (Appropriate ICD9 code is V03.1)
CPT 90691 - Typhoid vaccine, Vi capsular polysaccharide, intramuscular. Only for Very Select Children 2 years of age & over, Adolescents, & Adults who meet certain criteria. (Appropriate ICD9 code is V03.1)
CPT 90692 - Typhoid vaccine, heat &phenol inactivated. Only for Very Select Children 6 months of age & over, Adolescents, or Adults who meet certain criteria. (Appropriate ICD9 code is V03.1)
CPT 90696 - Diphtheria, tetanus toxoids, acellular pertussis vaccine & polio vaccine, inactivated. Children 4-6 years of age Only. (Appropriate ICD9 code is V06.8).
CPT 90698 - Diphtheria, tetanus toxoids, acellular pertussis vaccine, hemophilus influenza type b, and poliovirus vaccine. Infants & Children Only less than 4 (Appropriate ICD9 code is V06.8).
CPT 90700 – Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), when administered to individuals younger than 7 years, for intramuscular use (Appropriate ICD9 code is V06.1).
CPT 90702 – Diphtheria and tetanus toxoids (DT) adsorbed when administered to individuals younger than 7 years, for intramuscular use
CPT 90703 – Tetanus toxoid adsorbed, for intramuscular use
CPT 90704 – Mumps virus vaccine, live, for subcutaneous use (Appropriate ICD9 code is V04.6).
CPT 90705 – Measles virus vaccine, live, for subcutaneous use (Appropriate ICD9 code is V04.2).
CPT 90706 – Rubella virus vaccine, live, for subcutaneous use (Appropriate ICD9 code is V04.3).
CPT 90707 – Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use (Appropriate ICD9 code is V06.4).
CPT 90710 – Measles, mumps, rubella, and vericella vaccine (MMRV), live for subcutaneous use (Appropriate ICD9 code is V06.8).
CPT 90712 - Poliovirus vaccine, live, oral. Only for Very Select Children, Adolescents, or Adults who meet certain criteria. (Appropriate ICD9 code is V04.0).
CPT 90713 – Poliovirus vaccine, inactivated, (IPV), for subcutaneous or intramuscular use (Appropriate ICD9 code is V04.0).
CPT 90714 – Tetanus and diphtheria toxoids (Tc) absorbed, preservative free, when administered to individuals 7 years or older, for intramuscular use (Appropriate ICD9 code is V06.5).
CPT 90715 – Tetanus, diphtheria toxoids and acellular pertussis vaccine (TdaP), when administered to individuals 7 years or older, for intramuscular use (Appropriate ICD9 code is V06.1).
CPT 90716 – Varicella virus vaccine, live, for subcutaneous use (Appropriate ICD9 code is V06.4).
CPT 90717 - Yellow fever vaccine, live. Only for Very Select Infants, Children, Adolescents, or Adults who meet certain criteria. For travel to endemic areas or for laboratory workers. (Appropriate ICD9 code is V04.4).
CPT 90718 – Tetanus and diphtheria toxoids (Td) adsorbed when administered to individuals 7 years or older, for intramuscular use (Appropriate ICD9 code is V06.5).
CPT 90721 – DTAP/HIB Vaccine
CPT 90723 - Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitis B, and poliovirus vaccine, inactivated.  Infants, beginning at age 6 weeks, and Children up to age 7 years.  
CPT 90732 – Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use (Appropriate ICD9 code is V03.82).
CPT 90733 – Meningococcal polysaccharide vaccine (any group(s)), for subcutaneous use (Appropriate ICD9 code is V03.89).
CPT 90734 – Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 (tetravalent), for intramuscular use (Appropriate ICD9 code is V03.9).
CPT 90735 - Japanese encephalitis virus vaccine. Vaccine Not Commercially Available. Some Vaccine Available for Children & Adolescents 1-16 Years of Age thru Sanofi-Pasteur for Travel to Endemic Areas and for lab workers. (Appropriate ICD9 code is V05.0).
CPT 90736 – Zoster (shingles) vaccine, live, for subcutaneous injection Note: coverage for the Zoster vaccine is limited to age 60+ (Appropriate ICD9 code is V05.8).
CPT 90738 - Japanese encephalitis virus vaccine, inactivated. Adolescents age 17-18, and Adults, for Travel to Endemic Areas. (Appropriate ICD9 code is V05.0).
CPT 90740 – Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use
CPT 90743 – Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use (Appropriate ICD-9 code is V05.3)
CPT 90744 – Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use (Appropriate ICD-9 code is V05.3)
CPT 90746 – Hepatitis B vaccine, adult dosage, for intramuscular use (Appropriate ICD-9 code is V05.3)
CPT 90747 – Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use (Appropriate ICD-9 code is V05.3)
CPT 90748 – Hepatitis B and Hemophilus influenza b vaccine (HepB-Hib), for intramuscular use (Appropriate ICD9 code is V06.8 or V06.9).
CPT 90749 – Unlisted Vaccine Toxoid
 
PROSTATE CANCER SCREENING
Arkansas State Mandate
Act 75 of 2009 requires payment for prostate cancer screening annually for men age 40 and over as recommended by the National Comprehensive Cancer Network effective January 2009.
CPT/HCPCS Codes
CPT 84153
HCPCS G0102
HCPCS G0103
ICD-9 Code
V76.44 – Screen malignant neoplasm-prostate
 
MISCELLANEOUS PROCEDURES COVERED UNDER WELLNESS, BUT NOT LISTED UNDER PPACA, allowed only once a year in conjunction with an annual wellness exam
CPT/HCPCS Codes
CPT 99385
CPT 99386
CPT 99387
CPT 99395
CPT 99396
CPT 99387
CPT 80050
CPT 81000
CPT 81001
ICD9 Codes
V70.0 – General Medical Examination
 

CPT/HCPCS:
00810Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum
11980Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets beneath the skin)
11981Insertion, non-biodegradable drug delivery implant
11983Removal with reinsertion, non-biodegradable drug delivery implant
45330Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)
45331Sigmoidoscopy, flexible; with biopsy, single or multiple
45333Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery
45338Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
45339Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique
45378Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure)
45380Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple
45381Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance
45383Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique
45384Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery
45385Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
57170Diaphragm or cervical cap fitting with instructions
58300Insertion of intrauterine device (IUD)
58565Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants
58600Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral
58605Ligation or transection of fallopian tube(s), abdominal or vaginal approach, postpartum, unilateral or bilateral, during same hospitalization (separate procedure)
58611Ligation or transection of fallopian tube(s) when done at the time of cesarean delivery or intra-abdominal surgery (not a separate procedure) (List separately in addition to code for primary procedure)
58615Occlusion of fallopian tube(s) by device (eg, band, clip, Falope ring) vaginal or suprapubic approach
58661Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy)
58671Laparoscopy, surgical; with occlusion of oviducts by device (eg, band, clip, or Falope ring)
58720Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure)
59425Antepartum care only; 4-6 visits
59426Antepartum care only; 7 or more visits
77051Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further review for interpretation, with or without digitization of film radiographic images; diagnostic mammography (List separately in addition to code for primary procedure)
77052Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further review for interpretation, with or without digitization of film radiographic images; screening mammography (List separately in addition to code for primary procedure)
77055Mammography; unilateral
77056Mammography; bilateral
77057Screening mammography, bilateral (2-view film study of each breast)
77080Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine)
80050General health panel This panel must include the following: Comprehensive metabolic panel (80053) Blood count, complete (CBC), automated and automated differential WBC count (85025 or 85027 and 85004) OR Blood count, complete (CBC), automated (85027) and appropriate manual differential WBC count (85007 or 85009) Thyroid stimulating hormone (TSH) (84443)
80055Obstetric panel This panel must include the following: Blood count, complete (CBC), automated and automated differential WBC count (85025 or 85027 and 85004) OR Blood count, complete (CBC), automated (85027) and appropriate manual differential WBC count (85007 or 85009) Hepatitis B surface antigen (HBsAg) (87340) Antibody, rubella (86762) Syphilis test, non-treponemal antibody; qualitative (eg, VDRL, RPR, ART) (86592) Antibody screen, RBC, each serum technique (86850) Blood typing, ABO (86900) AND Blood typing, Rh (D) (86901)
80061Lipid panel This panel must include the following: Cholesterol, serum, total (82465) Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol) (83718) Triglycerides (84478)
81000Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy
81001Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy
81025Urine pregnancy test, by visual color comparison methods
81211BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis and common duplication/deletion variants in BRCA1 (ie, exon 13 del 3.835kb, exon 13 dup 6kb, exon 14-20 del 26kb, exon 22 del 510bp, exon 8-9 del 7.1kb)
81212BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and ovarian cancer) gene analysis; 185delAG, 5385insC, 6174delT variants
81213BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and ovarian cancer) gene analysis; uncommon duplication/deletion variants
81214BRCA1 (breast cancer 1) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis and common duplication/deletion variants (ie, exon 13 del 3.835kb, exon 13 dup 6kb, exon 14-20 del 26kb, exon 22 del 510bp, exon 8-9 del 7.1kb)
81215BRCA1 (breast cancer 1) (eg, hereditary breast and ovarian cancer) gene analysis; known familial variant
81216BRCA2 (breast cancer 2) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis
81217BRCA2 (breast cancer 2) (eg, hereditary breast and ovarian cancer) gene analysis; known familial variant
82270Blood, occult, by peroxidase activity (eg, guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (ie, patient was provided 3 cards or single triple card for consecutive collection)
82274Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations
82465Cholesterol, serum or whole blood, total
82947Glucose; quantitative, blood (except reagent strip)
82950Glucose; post glucose dose (includes glucose)
83020Hemoglobin fractionation and quantitation; electrophoresis (eg, A2, S, C, and/or F)
83021Hemoglobin fractionation and quantitation; chromatography (eg, A2, S, C, and/or F)
83036Hemoglobin; glycosylated (A1C)
83655Lead
83718Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol)
84030Phenylalanine (PKU), blood
84153Prostate specific antigen (PSA); total
84436Thyroxine; total
84437Thyroxine; requiring elution (eg, neonatal)
84439Thyroxine; free
84443Thyroid stimulating hormone (TSH)
84478Triglycerides
84703Gonadotropin, chorionic (hCG); qualitative
85013Blood count; spun microhematocrit
85014Blood count; hematocrit (Hct)
85018Blood count; hemoglobin (Hgb)
85025Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count
85027Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count)
86580Skin test; tuberculosis, intradermal
86592Syphilis test, non-treponemal antibody; qualitative (eg, VDRL, RPR, ART)
86689Antibody; HTLV or HIV antibody, confirmatory test (eg, Western Blot)
86701Antibody; HIV-1
86703Antibody; HIV-1 and HIV-2, single result
86780Antibody; Treponema pallidum
86901Blood typing; Rh (D)
87081Culture, presumptive, pathogenic organisms, screening only;
87084Culture, presumptive, pathogenic organisms, screening only; with colony estimation from density chart
87086Culture, bacterial; quantitative colony count, urine
87088Culture, bacterial; with isolation and presumptive identification of each isolate, urine
87270Infectious agent antigen detection by immunofluorescent technique; Chlamydia trachomatis
87320Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Chlamydia trachomatis
87340Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; hepatitis B surface antigen (HBsAg)
87390Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; HIV-1
87490Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, direct probe technique
87491Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique
87535Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, amplified probe technique, includes reverse transcription when performed
87590Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, direct probe technique
87591Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe technique
87621Infectious agent detection by nucleic acid (DNA or RNA); papillomavirus, human, amplified probe technique
87800Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s) technique
87801Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified probe(s) technique
87810Infectious agent antigen detection by immunoassay with direct optical observation; Chlamydia trachomatis
87850Infectious agent antigen detection by immunoassay with direct optical observation; Neisseria gonorrhoeae
88141Cytopathology, cervical or vaginal (any reporting system), requiring interpretation by physician
88142Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; manual screening under physician supervision
88143Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; with manual screening and rescreening under physician supervision
88147Cytopathology smears, cervical or vaginal; screening by automated system under physician supervision
88148Cytopathology smears, cervical or vaginal; screening by automated system with manual rescreening under physician supervision
88150Cytopathology, slides, cervical or vaginal; manual screening under physician supervision
88151Cytopathology, smears, cervical or vaginal, up to three smears; requiring interpretation by physician (Consider using 88141)
88152Cytopathology, slides, cervical or vaginal; with manual screening and computer-assisted rescreening under physician supervision
88153Cytopathology, slides, cervical or vaginal; with manual screening and rescreening under physician supervision
88154Cytopathology, slides, cervical or vaginal; with manual screening and computer-assisted rescreening using cell selection and review under physician supervision
88164Cytopathology, slides, cervical or vaginal (the Bethesda System); manual screening under physician supervision
88165Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and rescreening under physician supervision
88166Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and computer-assisted rescreening under physician supervision
88167Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and computer-assisted rescreening using cell selection and review under physician supervision
88174Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; screening by automated system, under physician supervision
88175Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; with screening by automated system and manual rescreening or review, under physician supervision
88305Level IV - Surgical pathology, gross and microscopic examination Abortion - spontaneous/missed Artery, biopsy Bone marrow, biopsy Bone exostosis Brain/meninges, other than for tumor resection Breast, biopsy, not requiring microscopic evaluation of surgical margins Breast, reduction mammoplasty Bronchus, biopsy Cell block, any source Cervix, biopsy Colon, biopsy Duodenum, biopsy Endocervix, curettings/biopsy Endometrium, curettings/biopsy Esophagus, biopsy Extremity, amputation, traumatic Fallopian tube, biopsy Fallopian tube, ectopic pregnancy Femoral head, fracture Fingers/toes, amputation, non-traumatic Gingiva/oral mucosa, biopsy Heart valve Joint, resection Kidney, biopsy Larynx, biopsy Leiomyoma(s), uterine myomectomy - without uterus Lip, biopsy/wedge resection Lung, transbronchial biopsy Lymph node, biopsy Muscle, biopsy Nasal mucosa, biopsy Nasopharynx/oropharynx, biopsy Nerve, biopsy Odontogenic/dental cyst Omentum, biopsy Ovary with or without tube, non-neoplastic Ovary, biopsy/wedge resection Parathyroid gland Peritoneum, biopsy Pituitary tumor Placenta, other than third trimester Pleura/pericardium - biopsy/tissue Polyp, cervical/endometrial Polyp, colorectal Polyp, stomach/small intestine Prostate, needle biopsy Prostate, TUR Salivary gland, biopsy Sinus, paranasal biopsy Skin, other than cyst/tag/debridement/plastic repair Small intestine, biopsy Soft tissue, other than tumor/mass/lipoma/debridement Spleen Stomach, biopsy Synovium Testis, other than tumor/biopsy/castration Thyroglossal duct/brachial cleft cyst Tongue, biopsy Tonsil, biopsy Trachea, biopsy Ureter, biopsy Urethra, biopsy Urinary bladder, biopsy Uterus, with or without tubes and ovaries, for prolapse Vagina, biopsy Vulva/labia, biopsy
90376Rabies immune globulin, heat-treated (RIg-HT), human, for intramuscular and/or subcutaneous use
90396Varicella-zoster immune globulin, human, for intramuscular use
90460Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered
90461Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine or toxoid component administered (List separately in addition to code for primary procedure)
90472Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)
90473Immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid)
90474Immunization administration by intranasal or oral route; each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)
90632Hepatitis A vaccine, adult dosage, for intramuscular use
90633Hepatitis A vaccine, pediatric/adolescent dosage-2 dose schedule, for intramuscular use
90636Hepatitis A and hepatitis B vaccine (HepA-HepB), adult dosage, for intramuscular use
90645Hemophilus influenza b vaccine (Hib), HbOC conjugate (4 dose schedule), for intramuscular use
90646Hemophilus influenza b vaccine (Hib), PRP-D conjugate, for booster use only, intramuscular use
90647Hemophilus influenza b vaccine (Hib), PRP-OMP conjugate (3 dose schedule), for intramuscular use
90648Hemophilus influenza b vaccine (Hib), PRP-T conjugate (4 dose schedule), for intramuscular use
90649Human Papilloma virus (HPV) vaccine, types 6, 11, 16, 18 (quadrivalent), 3 dose schedule, for intramuscular use
90650Human Papilloma virus (HPV) vaccine, types 16, 18, bivalent, 3 dose schedule, for intramuscular use
90655Influenza virus vaccine, trivalent, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use
90656Influenza virus vaccine, trivalent, split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use
90657Influenza virus vaccine, trivalent, split virus, when administered to children 6-35 months of age, for intramuscular use
90658Influenza virus vaccine, trivalent, split virus, when administered to individuals 3 years of age and older, for intramuscular use
90660Influenza virus vaccine, trivalent, live, for intranasal use
90662Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use
90669Pneumococcal conjugate vaccine, 7 valent, for intramuscular use
90670Pneumococcal conjugate vaccine, 13 valent, for intramuscular use
90675Rabies vaccine, for intramuscular use
90676Rabies vaccine, for intradermal use
90680Rotavirus vaccine, pentavalent, 3 dose schedule, live, for oral use
90681Rotavirus vaccine, human, attenuated, 2 dose schedule, live, for oral use
90685Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use
90686Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to individuals 3 years of age and older, for intramuscular use
90688Influenza virus vaccine, quadrivalent, split virus, when administered to individuals 3 years of age and older, for intramuscular use
90690Typhoid vaccine, live, oral
90691Typhoid vaccine, Vi capsular polysaccharide (ViCPs), for intramuscular use
90692Typhoid vaccine, heat- and phenol-inactivated (H-P), for subcutaneous or intradermal use
90696Diphtheria, tetanus toxoids, acellular pertussis vaccine and poliovirus vaccine, inactivated (DTaP-IPV), when administered to children 4 through 6 years of age, for intramuscular use
90698Diphtheria, tetanus toxoids, acellular pertussis vaccine, haemophilus influenza Type B, and poliovirus vaccine, inactivated (DTaP - Hib - IPV), for intramuscular use
90700Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), when administered to individuals younger than 7 years, for intramuscular use
90702Diphtheria and tetanus toxoids (DT) adsorbed when administered to individuals younger than 7 years, for intramuscular use
90703Tetanus toxoid adsorbed, for intramuscular use
90704Mumps virus vaccine, live, for subcutaneous use
90705Measles virus vaccine, live, for subcutaneous use
90706Rubella virus vaccine, live, for subcutaneous use
90707Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use
90710Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use
90712Poliovirus vaccine, (any type[s]) (OPV), live, for oral use
90713Poliovirus vaccine, inactivated (IPV), for subcutaneous or intramuscular use
90714Tetanus and diphtheria toxoids (Td) adsorbed, preservative free, when administered to individuals 7 years or older, for intramuscular use
90715Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years or older, for intramuscular use
90716Varicella virus vaccine, live, for subcutaneous use
90717Yellow fever vaccine, live, for subcutaneous use
90718Tetanus and diphtheria toxoids (Td) adsorbed when administered to individuals 7 years or older, for intramuscular use
90721Diphtheria, tetanus toxoids, and acellular pertussis vaccine and Hemophilus influenza B vaccine (DtaP-Hib), for intramuscular use
90723Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitis B, and poliovirus vaccine, inactivated (DtaP-HepB-IPV), for intramuscular use
90732Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use
90733Meningococcal polysaccharide vaccine (any group(s)), for subcutaneous use
90734Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 (tetravalent), for intramuscular use
90735Japanese encephalitis virus vaccine, for subcutaneous use
90736Zoster (shingles) vaccine, live, for subcutaneous injection
90738Japanese encephalitis virus vaccine, inactivated, for intramuscular use
90740Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use
90743Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use
90744Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use
90746Hepatitis B vaccine, adult dosage (3 dose schedule), for intramuscular use
90747Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use
90748Hepatitis B and Hemophilus influenza b vaccine (HepB-Hib), for intramuscular use
90749Unlisted vaccine/toxoid
92552Pure tone audiometry (threshold); air only
92579Visual reinforcement audiometry (VRA)
92582Conditioning play audiometry
92586Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; limited
92587Distortion product evoked otoacoustic emissions; limited evaluation (to confirm the presence or absence of hearing disorder, 3-6 frequencies) or transient evoked otoacoustic emissions, with interpretation and report
96040Medical genetics and genetic counseling services, each 30 minutes face-to-face with patient/family
96110Developmental screening, with interpretation and report, per standardized instrument form
96372Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular
97001Physical therapy evaluation
97002Physical therapy re-evaluation
97110Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
97112Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities
97116Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing)
97750Physical performance test or measurement (eg, musculoskeletal, functional capacity), with written report, each 15 minutes
97802Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes
97803Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes
99173Screening test of visual acuity, quantitative, bilateral
99174Instrument-based ocular screening (eg, photoscreening, automated-refraction), bilateral
99381Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; infant (age younger than 1 year)
99382Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; early childhood (age 1 through 4 years)
99383Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; late childhood (age 5 through 11 years)
99384Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; adolescent (age 12 through 17 years)
99385Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 18-39 years
99386Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 40-64 years
99387Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 65 years and older
99391Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; infant (age younger than 1 year)
99392Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; early childhood (age 1 through 4 years)
99393Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; late childhood (age 5 through 11 years)
99394Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 years)
99395Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18-39 years
99396Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years
99397Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and older
99401Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes
99402Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes
99403Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 45 minutes
99404Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 60 minutes
99406Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes
99407Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes
99408Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes
99409Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; greater than 30 minutes
99461Initial care, per day, for evaluation and management of normal newborn infant seen in other than hospital or birthing center
A4261Cervical cap for contraceptive use
A4264Permanent implantable contraceptive intratubal occlusion device(s) and delivery system
A4281Tubing for breast pump, replacement
A4282Adapter for breast pump, replacement
A4283Cap for breast pump bottle, replacement
A4284Breast shield and splash protector for use with breast pump, replacement
A4285Polycarbonate bottle for use with breast pump, replacement
A4286Locking ring for breast pump, replacement
G0008Administration of influenza virus vaccine
G0009Administration of pneumococcal vaccine
G0010Administration of hepatitis B vaccine
G0101Cervical or vaginal cancer screening; pelvic and clinical breast examination
G0102Prostate cancer screening; digital rectal examination
G0103Prostate cancer screening; prostate specific antigen test (PSA)
G0104Colorectal cancer screening; flexible sigmoidoscopy
G0105Colorectal cancer screening; colonoscopy on individual at high risk
G0108Diabetes outpatient self-management training services, individual, per 30 minutes
G0109Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes
G0121Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk
G0123Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, screening by cytotechnologist under physician supervision
G0124Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, requiring interpretation by physician
G0141Screening cytopathology smears, cervical or vaginal, performed by automated system, with manual rescreening, requiring interpretation by physician
G0143Screening 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
G0144Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system, under physician supervision
G0145Screening 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
G0147Screening cytopathology smears, cervical or vaginal, performed by automated system under physician supervision
G0148Screening cytopathology smears, cervical or vaginal, performed by automated system with manual rescreening
G0159Services performed by a qualified physical therapist, in the home health setting, in the establishment or delivery of a safe and effective physical therapy maintenance program, each 15 minutes
G0202Screening mammography, producing direct digital image, bilateral, all views
G0206Diagnostic mammography, producing direct digital image, unilateral, all views
G0270Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face-to-face with the patient, each 15 minutes
G0306Complete CBC, automated (HgB, HCT, RBC, WBC, without platelet count) and automated WBC differential count
G0307Complete (CBC), automated (HgB, Hct, RBC, WBC; without platelet count)
G0328Colorectal cancer screening; fecal occult blood test, immunoassay, 1-3 simultaneous determinations
G0389Ultrasound B-scan and/or real time with image documentation; for abdominal aortic aneurysm (AAA) screening
G0432Infectious agent antibody detection by enzyme immunoassay (EIA) technique, HIV-1 and/or HIV-2, screening
G0433Infectious agent antibody detection by enzyme-linked immunosorbent assay (ELISA) technique, HIV-1 and/or HIV-2, screening
G0435Infectious agent antigen detection by rapid antibody test of oral mucosa transudate, HIV-1 or HIV-2, screening
G0436Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes
G0437Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 10 minutes
G0438Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit
G0439Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit
G0444Annual depression screening, 15 minutes
G0451Development testing, with interpretation and report, per standardized instrument form
J1050Injection, medroxyprogesterone acetate, 1 mg
J1055Injection, medroxyprogesterone acetate for contraceptive use, 150 mg
J7300Intrauterine copper contraceptive
J7301Levonorgestrel-releasing intrauterine contraceptive system (Skyla), 13.5 mg
J7302Levonorgestrel-releasing intrauterine contraceptive system, 52 mg
J7303Contraceptive supply, hormone containing vaginal ring, each
J7304Contraceptive supply, hormone containing patch, each
J7306Levonorgestrel (contraceptive) implant system, including implants and supplies
J7307Etonogestrel (contraceptive) implant system, including implant and supplies
P3000Screening Papanicolaou smear, cervical or vaginal, up to 3 smears, by technician under physician supervision
P3001Screening Papanicolaou smear, cervical or vaginal, up to 3 smears, requiring interpretation by physician
Q0091Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory
S0265Genetic counseling, under physician supervision, each 15 minutes
S0610Annual gynecological examination, new patient
S0612Annual gynecological examination, established patient
S3620Newborn metabolic screening panel, includes test kit, postage and the laboratory tests specified by the state for inclusion in this panel (e.g., galactose; hemoglobin, electrophoresis; hydroxyprogesterone, 17-d; phenylanine (PKU); and thyroxine, total)
S3645HIV-1 antibody testing of oral mucosal transudate
S4981Insertion of levonorgestrel-releasing intrauterine system
S4989Contraceptive intrauterine device (e.g., Progestacert IUD), including implants and supplies
S4993Contraceptive pills for birth control
S9131Physical therapy; in the home, per diem
S9140Diabetic management program, follow-up visit to non-MD provider
S9141Diabetic management program, follow-up visit to MD provider
S9452Nutrition classes, nonphysician provider, per session
S9455Diabetic management program, group session
S9460Diabetic management program, nurse visit
S9465Diabetic management program, dietitian visit
S9470Nutritional counseling, dietitian visit

ICD9
Procedure:

Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants.
CPT Codes Copyright © 2014 American Medical Association.