Preventive services/codes

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
    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*

    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*, 87341*

    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 SCEENING
    		 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
    OSTEOPOROESIS 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
    • 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
    • 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.