Preventive services/codes

Page last updated on: 6/29/25

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
diagnosis code

Guideline/source

ABDOMINAL AORTIC ANEURYSM SCREENING: Aortography

76706

Not specified

  • 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

BRCA SCREENING

Testing: 81162-81167, 81212, 81215, 81217

Counseling: 96040

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

77063, 77067

Not specified

  • Begin at age 30 for those at high risk
  • Women ages 40-74
  • Men and women: at doctor's discretion based on risk factors
  • Every 2 years
  • USPSTF Rating: B

See medical policy 91545, Breast Related Procedures

77061,77062, 77065, 77066
(billed when screening turns diagnostic; screening diagnosis required)

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*, 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

  • Women
  • Age 21-61
  • Every 3 years
  • USPSTF Rating: A

CERVICAL CANCER SCREENING (lab/path):
Human Papillomavirus (HPV)

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

 

  • 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*, 45390*
G0104, G0105, G0121

Z12.11-Z12.12, Z80.0, Z83.71, Z85.00-Z85.09, Z86.0100

  • Colonoscopy performed for screening purposes converted to diagnostic; bill with modifier 33 or PT
  • Age 45-75 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, medication.

Anesthesia code 00812, 99152*, 99153*, 99156*, 99157*, G0500
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

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:
CT colonography

74263

Not specified; prior authorization required

  • Age 45-75 years
  • Every 10 years
  • USPSTF Rating: I

COLORECTAL CANCER SCREENING:
Fecal DNA (Cologuard)

81528

See medical policy 91547, Colorectal Cancer Screening
  • Age 45-75 years
  • Every 3 years
  • USPSTF Rating: A

COLORECTAL CANCER SCREENING:
Fecal occult blood (FOB)

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

  • Age 45-75 years 
  • Annually
  • USPSTF Rating: A

Service

HCPCS/CPT codes

Required ICD-10
diagnosis code

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

 
  • Refer to plan documents to verify coverage
  • HRSA requirement

CONTRACEPTION:
Pregnancy test in relation to contraceptive services

81025

CONTRACEPTION:
Diaphragm, cervical cap, vaginal ring, etc.

57170, A4261, A4266, J7303, J7304

CONTRACEPTION:
Intrauterine device (IUD)

58300, 58301, J7296, J7297, J7298, J7300, J7301

CONTRACEPTION:
Implantable capsule

11976, 11981, 11982, 11983, 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*, 83037*

Z00.00-Z00.01, Z00.121-Z0.129, Z01.411, Z01.419, Z13.1, I10 (Hgb A1C)

  • 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
  • USPSTF Rating: B
FLUORIDE 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 HEMATOCRIT

85014*, 85018*

Z00.00-Z00.01, Z00.110-Z00.3, Z01.411, Z01.419, Z76.1, Z76.2

  • 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*

Z00.00-Z00.01, Z01.411, Z01.419, Z11.59, Z20.2, Z20.5, Z72.89

  • Persons at high risk for infection (sexually transmitted disease and shared needles)
  • USPSTF Rating: B

HEPATITIS C SCREENING

86803*
G0472

Z00.00-Z00.01, Z01.411, Z01.419, Z11.59, Z20.2, Z20.5, Z72.89

  • Age 18 - 79 years old
  • USPSTF Rating: B

HYPERLIPIDEMIA TESTING:
Lipid panel

80061*

Z00.00-Z00.01, Z00.121-Z00.129, Z01.411-Z01.419, Z13.220, Z13.6

  • Adults: Annually 
  • 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*

Z00.00-Z00.01, Z00.121, Z00.129, Z77.011

HRSA

LUNG CANCER SCREENING

Low-dose chest CT scan: 71271
Counseling: G0296

Not specified
Prior authorization required for the CT scan

  • Annual screen
  • Age 50-80
  • 20-pack year history
  • Current smoker or quit in past 15 years
  • USPSTF rating: B
OSTEOPOROSIS SCREENING: Central/axial DEXA scan

77080*, 77085*

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*, 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

  • Annual for adults at high risk
  • USPSTF Rating: A
  • HRSA for women

SEXUALLY TRANSMITTED INFECTION TESTING:
Syphilis

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:
Gonorrhea

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:
Chlamydia

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

  • USPSTF Rating: A
  • Women only

STERILIZATION:
Salpingectomy (starting January 1, 2021)

58661, 58700, 58720

Z30.2

  • Women only
  • Refer to plan documents to verify coverage
  • HRSA requirement

STERILIZATION:
Tubal occlusion device

58565 (includes implant), 58615, 58340, 74740

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

Z30.2, Z98.51

  • Women only
  • Refer to plan documents to verify coverage
  • HRSA requirement

TUBERCULOSIS TESTING

86580*, 86480*, 86481*

Z00.00-Z00.01, Z00.110-Z00.3, Z01.411, Z01.419,  Z11.1,  Z76.1-Z76.2

  • 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:
Also see Well-child visit information

Includes age- and gender- appropriate counseling & screening for:

  • Blood pressure
  • Chemoprevention for high risk of breast cancer
  • Contraception methods
  • Dietary counseling
  • Dyslipidemia 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
  • Vision screening (bundled with E&M service, codes 99172-99173 not separately payable)

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:
Ambulatory blood pressure monitoring (ABPM)

93784-93790

R03.0, I10

  • Confirmation of hypertension using ABPM
  • HRSA Rating: A

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

96160, 96161

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

Not specified

USPSTF Rating: A

WELL PHYSICAL EXAM:
Vision screening

99172 - 99173
Bundled with E&M service

Not specified

  • Age 3, 4, 5, 6, 8, 10, 12, 15, 18 years
  • USPSTF Rating: B

Service

HCPCS/CPT codes

Required ICD-10
diagnosis code

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.