Provider Manual

 
 

Preventive service billing and coding reference

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

Exceptions:

  • Self-funded employer groups may individualize their plan benefits, which may override the Preventive Health Care Guidelines.
  • Some "grandfathered" plans may have copays for preventive services, and/or a different list of preventive services.
  • Certain religious employers can claim exemption from the contraceptive methods, counseling and sterilizations for women.
  • Certain religious organizations can claim a safe harbor exemption from covering contraceptive methods and counseling.

More information on vaccinations/immunizations in this Manual

Jump down this page to:

Routine maternity care codes

Key:

* = You may use modifier 33 to identify that this service was performed for indications described under the Priority Health Preventive Health Care Guidelines. Applies to claims for commercial plan members only. This excludes codes billed with payment modifiers such as 26, 52, TC, etc.

ACIP = Advisory Committee on Immunization Practices

HHS = Health and Human Services

HRSA: = Health Resources and Services Administration

PPACA = Patient Protection and Affordable Care Act of 2010

USPSTF = United States Preventive Services Task Force

Service HCPCS/CPT codes Required ICD-10
diagnosis code
Guideline/source
ABDOMINAL AORTIC ANEURYSM SCREENING: Aortography 76770*, 76775*, G0389

ICD-10:
Z87.891, Z00.00-Z00.01, Z13.6

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

At time of physical exam - payable to professional only

See details in this Manual

BRCA SCREENING Testing: 81211-81217
Counseling: 96040, S0265

ICD-10:
Z80.3, Z80.41, Z80.49, Z85.3, Z85.43, Z15.01

  • Women at high risk for breast or ovarian cancer
  • USPSTF Rating: B
  • Once per lifetime
BREAST CANCER SCREENING:
Mammography
77052, 77057, 77063, G0202 Not specified
  • Women age 30-49 high risk
  • Women age 50-74
  • Every 2 years
  • USPSTF Rating: B

See medical policy 91545, Breast Related Procedures

77055, 77056, G0204-G0206, 77051 (billed when screening turns diagnostic; screening diagnosis required)

ICD-10:
Z85.3, Z80.3, Z12.31, Z12.39

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

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

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

Not specified for G codes

ICD-10:
Z00.00-Z00.01, Z00.121-Z00.129, Z01.411, Z01.419, Z12.4, Z12.72, Z72.51-Z72.53, Z80.41, Z80.49

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

87623*, 87624*, 87625*

ICD-10:
Z00.00-Z00.01, Z01.411, Z01.419, Z11.3, Z11.4, Z11.51, Z11.59, Z12.4, Z12.72, Z7.189, Z72.51-Z72.53, Z80.41, Z80.49

 

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

COLORECTAL CANCER SCREENING:
Colonoscopy, sigmoidoscopy

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

ICD-10:
Z12.11-Z12.12, Z80.0, Z83.71, Z85.00-Z85.09, Z86.010

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

See medical policy 91547, Colorectal Cancer Screening

Facility charges for surgical/treatment room, supplies, anesthesia (00810), medication.

Anesthesia code 00810 should be billed with modifier PT or 33 if procedure is converted from screening to therapeutic.

Pathology: 88305

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

ICD-10:
Z12.11-Z12.12, Z80.0, Z83.71, Z85.00-Z85.01, Z85.020, Z85.028, Z85.030, Z85.038, Z85.040, Z85.048, Z85.810, Z85.818, Z85.819, Z86.010

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

    ICD-10:
    Z00.00-Z00.01, Z12.11-Z12.12, Z80.0, Z83.71, Z85.00-Z85.01, Z85.020, Z85.028, Z85.030, Z85.038, Z85.040, Z85.048, Z85.810, Z85.818, Z85.819, Z86.010

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

    ICD-10:
    Z30.011-Z30.09; Z30.40-Z30.9, Z31.61-Z31.69, Z97.5

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

    ICD-10:
    Z00.00-Z00.01, Z01.411, Z01.419, Z13.1

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

    Not specified

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

    ICD-10:
    Z00.00-Z00.01, Z00.110-Z00.3, Z01.411, Z01.419, Z12.4, Z12.72, Z76.1-Z76.2, Z80.0, Z85.00-Z85.09

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

    ICD-10:
    Z00.00-Z00.01, Z01.411, Z01.419, Z11.4, Z11.59, Z22.50-Z22.52

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

    ICD-10:
    Z00.00-Z00.01, Z01.411, Z01.419, Z11.4, Z11.59, Z22.50-Z22.52

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

    ICD-10:
    Z00.00-Z00.01, Z00.121-Z00.129, Z13.220, Z13.6

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

    ICD-10:
    Z00.00-Z00.01, Z00.121, Z00.129, Z77.011

    HRSA
    LUNG CANCER SCEENING:
    Low-dose chest CT scan
    G0297 Not specified - prior authorization required
    • Annual screen
    • Age 55-80
    • 30-pack year history
    • Current smoker or quit in past 15 years
    • USPSTF rating: B

    See medical policy 91600, Computed Tomography Scanning for Lung Cancer Screening

    OSTEOPOROESIS SCREENING: Central/axial DEXA scan 77080*, 77085*

    ICD-10:
    Z00.00, Z00.01, Z13.820, Z78.0

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

    See medical policy 91494, Bone Density Studies

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

    Not specified for G codes

    ICD-10: 
    Z00.00-Z00.01, Z01.411, Z01.419, Z11.3, Z11.4, Z11.59, Z71.7, Z71.89, Z72.51-Z72.53

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

    ICD-10:
    Z00.00-Z00.01, Z01.411-Z01.419, Z11.3, Z71.89, Z72.51-Z72.53

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

    ICD-10:
    Z00.00-Z00.01, Z00.121 – Z00.129, Z01.411-Z01.419, Z11.3, Z71.89, Z72.51-Z72.53

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

    ICD-10:
    Z00.00-Z00.01, Z00.121-Z00.129, Z01.411-Z01.419, Z11.3, Z11.8, Z71.89, Z72.51-Z72.53

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

    ICD-9:
    V26.51, V25.2, V26.29

    ICD-10:
    Z30.2, Z98.51

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

    58600-58605, 58611, 58670, 58671

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

    ICD-10:
    Z30.2, Z98.51

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

    ICD-10:
    Z76.1-Z76.2, Z00.121-Z00.129

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

    WELL PHYSICAL EXAM:
    Includes age- and gender- appropriate counseling & screening for:

    • Blood pressure
    • Chemoprevention for high risk of breast cancer
    • Contraception methods
    • Dietary counseling
    • Dyslipedemia risk factors
    • Height, weight, Body mass index
    • Intimate partner violence
    • Lead exposure risk assessment
    • Medical history
    • Menopause
    • Obesity
    • Oral health risk (children)
    • Rectal exam of prostate
    • Pelvic & breast exam
    • Sexually Transmitted Infection counseling
    Use age appropriate code 99460 - 99463 99381 - 99397 Not specified
    • Newborn: 3-5 days post discharge
    • 0-2 years: 2, 4, 6, 9, 12, 15, 18 & 24 months
    • 3-6 years: 30 months and then yearly
    • 7-10 years: 1-2 years
    • 11-18 years: yearly
    • Age 19-21 years: 1-3 years
    • Age 22-64 years: 1-3 years
    • Age 65+: yearly
    • USPSTF Rating: B
    WELL PHYSICAL EXAM:
    Intensive cardiovascular disease counseling
    G0446    

    WELL PHYSICAL EXAM:
    Preventive medicine assessment and risk reduction counseling

    99401-99404, 99411, 99412 Not specified
    WELL PHYSICAL EXAM:
    Depression screening
    96127 Not specified
    WELL PHYSICAL EXAM:
    Health risk assessment
    99420 Not specified
    WELL PHYSICAL EXAM:
    Alcohol misuse screening and counseling
    99408, 99409 Not specified
    • Age 11 through adult
    • USPSTF Rating: B
    WELL PHYSICAL EXAM:
    Behavioral counseling for obesity
    G0447    
    WELL PHYSICAL EXAM:
    Smoking and tobacco cessation
    99406, 99407, G0436-G0437 Not specified USPSTF Rating: A
    Service HCPCS/CPT codes Required ICD-10
    diagnosis code
    Guideline/source
    VACCINATION

    Administration: 90460-90474

    Immunizations: 90620-90621, 90632, 90644, 90647-90651, 90655-90660, 90662, 90670, 90672, 90675-90688, 90696, 90698,-90702, 90707, 90710, 90713-90716, 90723, 90732-90734, 90736, 90740-90748, Q2034-Q2039

    Not specified

    ACIP recommendations for non-excluded vaccines

    Go to the vaccines billing section of this manual for up-to-date coverage information

    Go to Preventive Health Care Guidelines for age appropriate vaccines and schedules

    VENIPUNCTURE 36415*, 36416* Use the code that qualifies the specific blood test as preventive.
    VISION SCREENING 99172 - 99173 Not specified
    • Age 3, 4, 5, 6, 8, 10, 12, 15, 18 years
    • USPSTF Rating: B

    * = You may use modifier 33 to identify that this service was performed for indications described under the Priority Health Preventive Health Care Guidelines. Applies to claims for commercial plan members only. This excludes codes billed with payment modifiers such as 26, 52, TC, etc.

    Routine maternity care

    Routine maternity is not synonymous with preventive benefit with no cost share. Consult plan documents for specific routine maternity benefits. Self-funded plans with a Maternity exclusion for dependents will deny all services except routine lab work listed below.

    **Test included in OB Panel; screening is typically performed using the OB panel

    Service HCPCS/CPT codes Required ICD-10
    diagnosis code
    Guideline/source
    BACTERIURIA SCREENING 81000-81003

    ICD-10:
    O07.0-O9a.53, Z33.1, Z34.00-Z37.9, Z39.0-Z39.2

    • At 12-16 weeks gestation or 1st prenatal visit
    • USPSTF Rating: A
    BREASTFEEDING SUPPORT

    Counseling, education: S9443

    Supplies: A4281-AA4286, E0602, E0603

    Not specified
    • Pregnant and lactating women
    • USPSTF Rating: B
    • HRSA requirement
    BLOOD TESTING:
    Complete blood count 85025**, 85027**

    ICD-10:
    O07.0-O9a.53, Z33.1, Z34.00-Z37.9, Z39.0-Z39.2

    On a routine basis for iron deficiency anemia
    Blood typing 86900**
    Gestational diabetes
    screening
    82947, 82948, 82950, 82951, 82952
    • Women 24-28 weeks pregnant and those at high risk for gestational diabetes
    • USPSTF Rating: B
    • HRSA requirement
    Hemoglobin/hematocrit 85014**, 85018** First prenatal visit
    Hepatitis B screening 86704, 86340** USPSTF Rating: A
    Obstetric panel 80055, 80081  Priority Health routine pre-natal care as preventive
    RBC antibody screen 86850**
    Rh compatibility 86901
    • First prenatal visit and follow up for women at high risk
    • USPSTF Rating: A
    Rubella antibody 86762** USPSTF Rating: B
    Venipuncture 36415, 36416  Bill with preventive blood studies
    CERVICAL CANCER SCREENING:
    PAP Smear
    88141-88155, 88164-88167, 88174,88175

    ICD-10:
    O07.0-O9a.53, Z33.1, Z34.00-Z37.9, Z39.0-Z39.2

    HRSA requirement
    PRENATAL, POST-NATAL AND DELIVERY CARE 59400-59410, 59425-59515, 59610-59622 Not specified

    Priority Health may pay routine pre-natal care as preventive

    Cost-sharing applies to global and delivery codes for HSA plans

    99201-99215, 99241 -99245

    ICD-10:
    O07.0-O9a.53, Z33.1, Z34.00-Z37.9, Z39.0-Z39.2

    SEXUALLY TRANSMITTED INFECTION TESTING
    HIV 86701, 86702, 86703, 87806

    ICD-10:
    O07.0-O9a.53, Z33.1, Z34.00-Z37.9, Z39.0-Z39.2

    USPSTF Rating: A
    Syphilis 86592** USPSTF Rating: A
    Gonorrhea 87850, 87590, 87591, 87592 USPSTF Rating: B
    Chlamydia 87110, 87270, 87320, 87490, 87491, 87492  USPSTF Rating: B
    Human Papillomavirus
    (HPV)
    87623, 87624, 87625
    ULTRASOUND 76801 - 76817 Not specified Priority Health routine pre-natal care as preventive
    VACCINATIONS
    Administration 90460-90474 Not specified

    Go to the vaccines billing section of this Manual for coverage information

    ACIP Recommendations for non-excluded vaccines
    Hepatitis A, B 90632-90636, 90740-90747 Administer during pregnancy if at risk
    Influenza injection
    (excludes nasal spray)
    90630, 90654, 90662, 90685, 90686, 90688, Q2034-Q2038

    Flu vaccine recommended during pregnancy

    Go to the flu shots billing page in this Manual for details

    Meningococcal 90620, 90621, 90733, 90734 If indicated during pregnancy
    Pneumococcal 90670, 90732 If indicated during pregnancy
    Tetanus, diphtheria,
    whooping cough
    90702, 90714, 90715 One dose recommended during pregnancy

    **Test included in OB Panel; screening is typically performed using the OB panel

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    Last modified: 7/28/2016
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