Provider Manual

 
 

Preventive service billing and coding reference

These codes correlate to our Preventive Health Care Guidelines (848KB PDF), 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 to routine maternity care code reference

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 Provider 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, 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+
  • Every 5-10 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: 88350

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

  • Age 50+
  • Every 5-10 years
COLORECTAL CANCER SCREENING:
CT colonography
74623 Not specified; prior authorization required
  • Age 50+
  • Every 5-10 years
  • USPSTF Rating: I
COLORECTAL CANCER SCREENING:
Fecal DNA (Colguard)
81528 See medical policy 91547, Colorectal Cancer Screening
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+
  • Every 5-10 years
  • 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, Z13.80, 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, 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, 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 billing and payment 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 billing and payment section of this manual for up-to-date 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
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: 4/5/2016
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