Applies to:
Group commercial HMO, EPO, POS and PPO plans
Individual MyPriority® HMO, POS and PPO plans
Medicaid preventive services are determined by plan documents from the State of Michigan.
Definition:
Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems, when the member has no symptoms.
Preventive services billing
These codes correlate to services listed in our Preventive Health Care Guidelines, which apply to members of group HMO, POS and PPO plans and individual MyPriority® plans. Use this chart for reference only; refer to the current CPT manual for a complete description of each code and the most updated code lists.
* = Modifier 33 may be submitted to identify the service was performed for an indication described under the Priority Health Preventive Health Care Guidelines, for commercial products only
Exceptions:
- Self-funded employer groups may individualize their plan benefits, which may override the Preventive Health Care Guidelines.
- Some "grandfathered" plans may have copays for preventive services, and/or a different list of preventive services.
- Certain religious employers can claim exemption from the contraceptive methods, counseling and sterilizations for women.
- Certain religious organizations can claim a safe harbor exemption from covering contraceptive methods and counseling.
- Medicaid coverage is primarily determined by the State of Michigan. If no Medicaid-specific preventive coverage documentation exists, our preventive guidelines will apply.
Preventive service codes
Service | HCPCS/CPT codes | Required ICD-10 | Guideline/source |
---|---|---|---|
ABDOMINAL AORTIC ANEURYSM SCREENING: Aortography | 76706 | Not specified |
|
ADVANCE CARE PLANNING | 99497, 99498 | Not specified | At time of physical exam - payable to professional only |
BRCA SCREENING | Testing: 81162-81167, 81212, 81215, 81217 Counseling: 96040 | Z80.3, Z80.41, Z80.49, Z85.3, Z85.43, Z15.01 |
|
BREAST CANCER SCREENING: | 77063, 77067 | Not specified |
See medical policy 91545, Breast Related Procedures |
77061,77062, 77065, 77066 | Z85.3, Z80.3, Z12.31, Z12.39 | ||
Service | HCPCS/CPT codes | Required ICD-10 | Guideline/source |
CERVICAL CANCER SCREENING (lab/path): | G0123, G0124, G0141, G0142, G0143, G0144, G0145, G0146, G0147, G0148 88141*, 88142*, 88143*, 88147*, 88148*, 88150*, 88152*, 88153*, 88155*, 88164*, 88165*, 88166*, 88167*, 88174*, 88175* | Not specified for G codes Z00.00-Z00.01, Z00.121-Z00.129, Z01.411, Z01.419, Z12.4, Z12.72, Z72.51-Z72.53, Z80.41, Z80.49 |
|
CERVICAL CANCER SCREENING (lab/path): | 87623*, 87624*, 87625*, 87626* | Z00.00-Z00.01, Z00.121 - Z00.129, Z01.411, Z01.419, Z11.3, Z11.4, Z11.51, Z11.59, Z12.4, Z12.72, Z7.189, Z72.51-Z72.53, Z80.41, Z80.49
|
|
COLORECTAL CANCER SCREENING: | 45330*, 45331*, 45333*, 45334*, 45335*, 45338*, 45346*, 45378*, 45380*, 45381*, 45382*, 45383*, 45384*, 45385*, 45388*, 45390* | Z12.11-Z12.12, Z80.0, Z83.71, Z85.00-Z85.09, Z86.0100 |
See medical policy 91547, Colorectal Cancer Screening |
Facility charges for surgical/treatment room, supplies, anesthesia, medication. Anesthesia code 00812, 99152*, 99153*, 99156*, 99157*, G0500 Pathology: 88305 Office visit/consult with gastroenterologist before screening colonoscopy if medically necessary: S0285 | Z12.11-Z12.12, Z80.0, Z83.71, Z85.00-Z85.01, Z85.020, Z85.028, Z85.030, Z85.038, Z85.040, Z85.048, Z85.810, Z85.818, Z85.819, Z86.0100 | ||
COLORECTAL CANCER SCREENING: | 74263 | Not specified; prior authorization required |
|
COLORECTAL CANCER SCREENING: | 81528 | See medical policy 91547, Colorectal Cancer Screening |
|
COLORECTAL CANCER SCREENING: | 82270*, 82274*, G0328 | Z00.00-Z00.01, Z12.11-Z12.12, Z80.0, Z83.71, Z85.00-Z85.01, Z85.020, Z85.028, Z85.030, Z85.038, Z85.040, Z85.048, Z85.810, Z85.818, Z85.819, Z86.010 |
|
Service | HCPCS/CPT codes | Required ICD-10 | Guideline/source |
CONTRACEPTION: Management and family planning office visits | 99201-99215 | Z30.011-Z30.09; Z30.40-Z30.9, Z31.61-Z31.69, Z97.5 |
|
CONTRACEPTION: | 81025 | ||
CONTRACEPTION: | 57170, A4261, A4266, J7303, J7304 | ||
CONTRACEPTION: | 58300, 58301, J7296, J7297, J7298, J7300, J7301 | ||
CONTRACEPTION: | 11976, 11981, 11982, 11983, J7307 | ||
CONTRACEPTION: | J1050, 96372 | ||
Service | HCPCS/CPT codes | Required ICD-10 | Guideline/source |
DEVELOPMENTAL\AUTISM SCREENING | 96110 | Not specified |
|
DIABETES SCREENING | 82947*, 82948*, 83036*, 83037* | Z00.00-Z00.01, Z00.121-Z0.129, Z01.411, Z01.419, Z13.1, I10 (Hgb A1C) |
|
DIETARY COUNSELING | 97802, 97803, 97804 | Not specified |
|
FLUORIDE VARNISH APPLICATION | 99188 | Not specified |
|
HEARING SCREENING | 92551, V5008 | Not specified |
|
HEMOGLOBIN or HEMATOCRIT | 85014*, 85018* | Z00.00-Z00.01, Z00.110-Z00.3, Z01.411, Z01.419, Z76.1, Z76.2 |
|
Service | HCPCS/CPT codes | Required ICD-10 | Guideline/source |
HEPATITIS B SCREENING | 86704 - 86707*, 87340* | Z00.00-Z00.01, Z01.411, Z01.419, Z11.59, Z20.2, Z20.5, Z72.89 |
|
HEPATITIS C SCREENING | 86803* | Z00.00-Z00.01, Z01.411, Z01.419, Z11.59, Z20.2, Z20.5, Z72.89 |
|
HYPERLIPIDEMIA TESTING: | 80061* | Z00.00-Z00.01, Z00.121-Z00.129, Z01.411-Z01.419, Z13.220, Z13.6 |
|
HYPERLIPIDEMIA TESTING: | 82465*, 83718*, 83721*, 84478* | ||
LEAD TESTING | 83655* | Z00.00-Z00.01, Z00.121, Z00.129, Z77.011 | HRSA |
LUNG CANCER SCREENING | Low-dose chest CT scan: 71271 | Not specified |
|
OSTEOPOROSIS SCREENING: Central/axial DEXA scan | 77080*, 77085* | Z00.00, Z00.01, Z13.820, Z78.0 |
See medical policy 91494, Bone Density Studies |
Service | HCPCS/CPT codes | Required ICD-10 | Guideline/source |
SEXUALLY TRANSMITTED INFECTION TESTING: | G0432-G0433, G0435, 86701*, 86702*, 86703*, 87806*, 87389* | Not specified for G codes Z00.00-Z00.01, Z01.411, Z01.419, Z11.3, Z11.4, Z11.59, Z20.2, Z20.6, Z71.7, Z71.89, Z72.51-Z72.53 |
|
SEXUALLY TRANSMITTED INFECTION TESTING: | 86592*, 86593*, 86780* | Z00.00-Z00.01, Z01.411-Z01.419, Z11.3, Z20.2, Z71.89, Z72.51-Z72.53 | USPSTF Rating: A |
SEXUALLY TRANSMITTED INFECTION TESTING: | 87850*, 87590*, 87591*, 87592* | Z00.00-Z00.01, Z00.121 – Z00.129, Z01.411-Z01.419, Z11.3, Z20.2, Z71.89, Z72.51-Z72.53 | USPSTF Rating: A |
SEXUALLY TRANSMITTED INFECTION TESTING: | 87110*, 87270*, 87320*, 87490*, 87491*, 87492* | Z00.00-Z00.01, Z00.121-Z00.129, Z01.411-Z01.419, Z11.3, Z11.8, Z20.2, Z71.89, Z72.51-Z72.53 |
|
STERILIZATION: | 58661, 58700, 58720 | Z30.2 |
|
STERILIZATION: | 58565 (includes implant), 58615, 58340, 74740 | Z30.2, Z98.51 |
|
STERILIZATION: | 58600-58605, 58611, 58670, 58671 Facility charges for surgery/treatment room, supplies, anesthesia (00851, 00952), lab, medication | Z30.2, Z98.51 |
|
TUBERCULOSIS TESTING | 86580*, 86480*, 86481* | Z00.00-Z00.01, Z00.110-Z00.3, Z01.411, Z01.419, Z11.1, Z76.1-Z76.2 |
|
Service | HCPCS/CPT codes | Required ICD-10 | Guideline/source |
WELL PHYSICAL EXAM: Includes age- and gender- appropriate counseling & screening for:
| Use age appropriate code 99460 - 99463 99381 - 99397 | Not specified |
|
WELL PHYSICAL EXAM: | 93784-93790 | R03.0, I10 |
|
WELL PHYSICAL EXAM: | G0446 | ||
WELL PHYSICAL EXAM: | 99401-99404, 99411, 99412 | Not specified | |
WELL PHYSICAL EXAM: | 96127 | Not specified | |
WELL PHYSICAL EXAM: | 96160, 96161 | Not specified | |
WELL PHYSICAL EXAM: | 99408, 99409 | Not specified |
|
WELL PHYSICAL EXAM: | G0447 | ||
WELL PHYSICAL EXAM: | 99406, 99407 | Not specified | USPSTF Rating: A |
WELL PHYSICAL EXAM: | 99172 - 99173 | Not specified |
|
Service | HCPCS/CPT codes | Required ICD-10 | Guideline/source |
VACCINATIONS | Go to the Vaccines chart for up-to-date coding and coverage information | ||
VENIPUNCTURE | 36415*, 36416* | Use the code that qualifies the specific blood test as preventive. |