Coding for preventive services

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
BREAST CANCER SCREENING: Mammography	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
COLORECTAL CANCER SCREENING: Colonoscopy, sigmoidoscopy	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.

For Providers

Preventive services/codes

Applies to:

Definition:

Preventive services billing

Exceptions:

Preventive service codes