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L.2.01.409
This policy outlines the criteria for coverage of preventive health services under the Federal Healthcare Reform, Patient Protection and Affordable Care Act (PPACA). The goals of preventive health services are to avoid the development of disease and to diagnose disease in its early stages before it results in significant morbidity.
Blue Cross & Blue Shield of Mississippi currently covers annual health screenings and immunizations based on age and gender under our Healthy You! wellness benefit. Healthy You! Wellness Procedures are addressed in a separate policy. Under PPACA, Blue Cross & Blue Shield of Mississippi will provide coverage for additional preventive health services based on –
Services recommended by the US Preventive Services Task Force (USPSTF)
Immunizations recommended by the Advisory Committee on Immunization Practices of the CDC
Preventive care and screenings for infants, children and adolescents supported by the Health Resources and Services Administration (HRSA)
Preventive care and screenings for women supported by the Health Resources and Services Administration (HRSA)
The “Policy” section below provides the specific coverage guidelines for each preventive health service that must be covered under PPACA at 100% without cost-sharing when delivered by a Network Provider. It also outlines the preventive health services covered as part of the Healthy You! wellness benefit at 100% without cost-sharing when provided by a Network Provider. Preventive health services provided by Non-Network Providers are not covered, except as specifically stated below with cost-sharing.
Please note that the Cologuard™ Fecal DNA test is not covered at 100% under PPACA because the provider of Cologuard, Exact Sciences Corporation, is not a Blue Cross & Blue Shield of Mississippi Network Provider. Therefore, the member will be financially responsible for a cost-share of the Cologuard screening because the services are out-of network. Providers are encouraged to discuss with their patients the various colorectal cancer screening methods and testing options, including colonoscopy, sigmoidoscopy, and fecal occult blood tests available from Network Providers.
A. Pregnant WomenThe following preventive services are covered for pregnant women.*An asterisk denotes preventive services with associated risk factors that must be documented to support medical necessity. The risk factors are outlined in the Policy section.1. Screening for anemia during pregnancy2. Breast feeding support3. Breast feeding equipment4. Chlamydia Screening*5. Syphilis Screening*6. Gonorrhea Screening*7. Hepatitis B Screening*8. HIV Screening9. Rh (D) Incompatibility10. Bacteriuria Screening11. Gestational Diabetes Screening*12. Folic Acid Supplementation13. Low-Dose Aspirin Use for the Prevention of Morbidity and Mortality From Preeclampsia*14. Prenatal Visit with Pediatrician*15. Screening for Diabetes Mellitus after Pregnancy*
B. NewbornsThe following preventive services are covered for newborns.1. Hemoglobinopathy Screening (Sickle Cell Disease)2. Congenital Hypothyroidism Screening3. Phenylketonuria (PKU) Screening4. Newborn Hearing Screening5. Prophylactic Medication to Prevent Gonorrhea in Newborns6. Critical Congenital Heart Defect Screening7. Newborn Outpatient Visit
C. Individuals Ages 0 – 21 YearsThe following preventive services are covered for individuals age 0 -21 years.*An asterisk denotes preventive services with associated risk factors that must be documented to support medical necessity. The risk factors are outlined in the Policy section.1. Lead Screening*2. TB Testing*3. Vision Screening4. Hearing Screening5. Developmental Screening6. Autism Screening7. Depression Screening8. Anxiety in Children and Adolescents: Screening9. Chlamydia Screening*10. Syphilis Screening*11. Gonorrhea Screening*12. HIV Screening13. Iron Supplementation*14. Fluoride Supplementation*15. Immunizations16. Alcohol and Drug Use Assessment17. Dental Caries Prevention in Children Age 5 Years and Younger18. Hepatitis B Virus Infection Screening: Non-Pregnant Adolescents and Adults*19. Latent Tuberculosis Screening: Adults*20. Oral Health Risk Assessment21. Prevention of Human Immunodeficiency Virus (HIV) Infection: Pre-Exposure Prophylaxis*22. Unhealthy Drug Use: Screening
D. Women 21 Years and OlderThe following preventive services are covered for women 21 years and older.*An asterisk denotes preventive services with associated risk factors that must be documented to support medical necessity. The risk factors are outlined in the Policy section.1. Chlamydia Screening*2. Syphilis Screening*3. Gonorrhea Screening*4. HIV Screening5. Risk Assessment, Genetic Counseling, and Genetic Testing for BRCA-Related Cancer*6. Folic Acid Supplementation7. Depression Screening8. Hepatitis B Virus Infection Screening: Non-Pregnant Adolescents and Adults*9. Hepatitis C Virus Infection Screening: Adults*10. Urinary Incontinence Screening
E. High Risk Population 21 Years and OlderThe following preventive services are covered for high risk population 21 years and older.*An asterisk denotes preventive services with associated risk factors that must be documented to support medical necessity. The risk factors are outlined in the Policy section.1. Screening for Abdominal Aortic Aneurysm*2. Syphilis Screening*3. HIV Screening4. Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer*5. Depression Screening6. Immunization7. Hepatitis B Virus Infection Screening: Non-Pregnant Adolescents and Adults*8. Hepatitis C Virus Infection Screening: Adults*9. Lung Cancer Screening* 10. Osteoporosis Screening: Women11. Breast Cancer Preventive Medication*12. Falls Prevention in Older Adults: Exercise or Physical Therapy*13. Falls Prevention in Older Adults: Vitamin D*14. Latent Tuberculosis Screening: Adults15. Colorectal Cancer Screening: Stool DNA Testing (Cologuard or Cologuard Plus)16. Colorectal Cancer Screening: Fecal Occult Blood Test (FOBT)17. Colorectal Cancer Screening: Follow-Up Colonoscopy18. Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: Preventive Medication*19. Prevention of Human Immunodeficiency Virus (HIV) Infection: Preexposure Prophylaxis*20. Unhealthy Drug Use: Screening
F. Other Preventive Health Services1. Tobacco Use Counseling: Pregnant Women2. Tobacco Use Interventions: Children and Adolescents3. Tobacco Use Counseling and Interventions: Non-Pregnant Adults4. Unhealthy Alcohol Use Counseling - Pregnancy, Adults 18+5. Obesity in Children and Adolescents: Screening*6. Weight Loss to Prevent Obesity-Related Morbidity and Mortality in Adults: Behavioral Interventions*7. Behavioral Counseling to Prevent Sexually Transmitted Infections*8. Healthy Diet and Physical Activity Counseling to Prevent Cardiovascular Disease9. Screening and Counseling for Domestic Violence10. Intimate Partner Violence: Screening11. Intimate Partner Violence: Ongoing Support Services*12. Skin Cancer Behavioral Counseling13. Anticipatory Guidance14. Perinatal Depression: Preventive Interventions*15. Behavioral Counseling Interventions for Healthy Weight and Weight Gain in Pregnancy
G. Contraception Coverage and Counseling1. Patient education and counseling of contraceptive methods2. Prescription Drug Contraception3. Other Food and Drug Administration (FDA) approved contraceptive methods4. Intrauterine Devices (IUDs), Insertion, and Removal5. Inpatient tubal ligation with c- section delivery6. Inpatient tubal ligation post vaginal delivery7. Outpatient tubal ligation
Services billed outside of the preventive health services guidelines will be denied as a not medically necessary preventive procedure.
A. | Coverage of Preventive Health Services for Pregnant Women | ||||||
|---|---|---|---|---|---|---|---|
Service | Age/Sex | Interval/Limits | Policy | Risk Factors | Procedure Code(s) | ICD-9 Diagnosis Code(s) | ICD-10 Diagnosis Code(s) |
1. Screening for anemia during pregnancy USPSTF Recommendation: Routine screening for iron deficiency anemia in asymptomatic pregnant women | All pregnant women | 1 screening per pregnancy | Screening for anemia during pregnancy will be covered once per pregnancy. | None | 80055 80081 85025 85027 85013 85014 85018 | V22.0 V22.1 V22.2 V23.0 V23.2 V23.49 V23.81 V23.82 V23.85 V23.89 V23.9 V28.0 V28.89 V28.9 V72.42 V72.69 | Z34.00 - Z34.03 Z34.80 - Z34.83, Z34.91 - Z34.93, Z33.1, Z33.3, O09.00 - O09.03, O09.291, O09.291 - O09.299, O09.511 - O09.519, O09.521 - O09.529, O09.811 - O09.819, O09.70 - O09.73, O09.891 - O09.899, O09.90 - O09.93, Z36.2, Z36.5, Z36.89, Z36.9, Z32.01, Z01.89 |
2.Lactation/Breastfeeding support and counseling USPSTF Recommendation: Interventions to promote & support breastfeeding HRSA Recommendation: Comprehensive lactation support services (including consultation; counseling; education by clinicians and peer support services) during the antenatal, perinatal, and postpartum periods to optimize the successful initiation and maintenance of breastfeeding. | All pregnant women and new mothers | For the duration of breastfeeding | Lactation/Breastfeeding Support and interventions will be covered when provided: during lactation classes; by the inpatient hospital nursing staff; at the infant’s first Healthy You! visit at 2 weeks of age by the Healthy You! primary care provider; and for the duration of breastfeeding. | None | S9443 99401 99402 99403 99404 | V24.1 | Z39.1 |
3. Breastfeeding equipment: Manual Breast Pump USPSTF Recommendation: Interventions to promote & support breastfeeding | All breastfeeding mothers | 1 per pregnancy | One manual breast pump will be covered per pregnancy. | None | E0602 | V24.1 | Z39.1 |
Breastfeeding equipment: Electric Breast Pump USPSTF Recommendation: Interventions to promote & support breastfeeding | All breastfeeding mothers | 1 every 3 years | One electric breast pump will be covered every 3 years. | None | E0603 | V24.1 | Z39.1 |
Breastfeeding equipment: Electric Breast Pump Supplies USPSTF Recommendation: Interventions to promote & support breastfeeding | All breastfeeding mothers | 1 set per pregnancy | One set of electric breast pump supplies will be covered per pregnancy. | None | A4281-A4287,A4288 (A4288 New 10/01/2025) | V24.1 | Z39.1 |
Breastfeeding equipment: Electric Breast Pump Replacement Supplies USPSTF Recommendation: Interventions to promote & support breastfeeding | All breastfeeding mothers | 1 set per year | One set of electric breast pump replacement supplies will be covered per year. | None | A4281-A4287,A4288 (A4288 New 10/01/2025) | V24.1 | Z39.1 |
4. Chlamydia ScreeningUSPSTF Recommendation: Recommends screening for chlamydia in all pregnant women age 24 years and younger and in older women who are at increased risk for infection. | Pregnant women 24 and younger and older pregnant women at increased risk | 1 screening at the 1st prenatal visit | Chlamydia screening will be covered once for pregnant women aged 24 and younger and for older pregnant women who are at increased risk. | All sexually active women 24 years of age or younger are at increased risk for chlamydial infection.In addition to sexual activity and age, other risk factors for chlamydial infection include - a history of chlamydial or other sexually transmitted infection new or multiple sexual partners inconsistent condom use exchanging sex for money or drugs a sex partner with concurrent partners a sex partner with a sexually transmitted infection | 87110 87270 87320 87490 87491 87492 87810 | V20.81 V22.0 V22.1 V22.2 V23.81 V23.82 V23.89 V23.9 V28.0 V28.89 V28.9 V72.42 | O09.00 - O09.03, O09.291 - O09.299 O09.511 - O09.519, O09.521 - O09.529, O09.70 - O09.73, O09.811 - O09.819, O09.891 - O09.899, Z32.01, Z33.1, Z33.3, Z34.00 - Z34.03, Z34.80 - Z34.83, Z34.90 - Z34.93, Z36.2, Z36.5, Z36.89, Z36.9 |
Pregnant women with continued risk or new risk factor | 2nd screening must be performed in the 3rd trimester | A second chlamydia screening may be conducted in the 3rd trimester for pregnant women with new or continued risk. Risk factors must be documented by the healthcare provider. | For pregnant women who remain at increased risk and for those who acquire a new risk factor, such as a new sexual partner, a screening should be conducted during the third trimester. | 87110 87270 87320 87490 87491 87492 87810 | V23.0 V23.2 V23.49 V23.81 V23.82 V23.85 V23.9 | O09.00 - O09.03, O09.291 - O09.299, O09.511 - O09.519, O09.521 - O09.529, O09.70 - O09.73, O09.811 - O09.819, O09.891 - O09.899 | |
5. Syphilis ScreeningUSPSTF Recommendation: Recommends that clinicians screen all pregnant women for syphilis infection. | All pregnant women | 1 screening at the 1st prenatal visit | Syphilis screening will be covered for all pregnant women at the first prenatal visit. | None | 86592 86593 80055 80081 | V22.0 V22.1 V22.2 V23.9 V28.0 V28.89 V28.9 V72.42 | O09.90 - O09.93 Z32.01, Z33.1, Z33.3, Z34.00 - Z34.03 Z34.80 - Z34.83, Z34.90 - Z34.93 Z36.2, Z36.5, Z36.89, Z36.9 |
High-risk pregnant women | 2nd screening in the 3rd trimester AND 3rd screening at time of delivery included within the hospital DRG | For women in high-risk groups, repeat serologic testing for syphilis is recommended in the third trimester and at delivery. Risk factors must be documented by the healthcare provider. | Populations at increased risk for syphilis infection may include – living in communities or geographic areaswith higher prevalence of syphilis living with HIV commercial sex workers persons who exchange sex for drugs recently been in a correctional facility | 86592 86593 80055 80081 | V23.0 V23.2 V23.49 V23.81 V23.82 V23.85 V23.89 V23.9 | O09.00 - O09.03, O09.291 - O09.299, O09.511 - O09.519, O09.521 - O09.529, O09.70 - O09.73, O09.811 - O09.819, O09.891 - O09.899 | |
6. Gonorrhea ScreeningUSPSTF Recommendation: Recommends screening for gonorrhea in all pregnant women age 24 years and younger and in older women who are at increased risk for infection. | Pregnant women 24 and younger and older women who are at increased risk | 1 screening at the 1st prenatal visit 2nd screening in the 3rd trimester | Gonorrhea screening will be covered for all pregnant women 24 years of age and younger. The screening may be conducted twice during pregnancy. Gonorrhea screening will be covered for all pregnant women 25 years of age and older at increased risk for infection. | All sexually active women 24 years of age or younger are at increased risk for gonorrhea infection. In addition to sexual activity and age, other risk factors for gonorrhea include – a history of previous gonorrhea infection other sexually transmitted infections new or multiple sexual partners inconsistent condom use sex work drug use a sex partner with concurrent partners a sex partner with a sexually transmitted infection | 87590 87591 87592 87850 | V22.0 V22.1 V22.2 V23.0 V23.2 V23.49 V23.81 V23.82 V23.85 V23.89 V23.9 V28.9 V72.42 V73.99 | O09.00 - O09.03, O09.291 - O09.299, O09.511 - O09.519, O09.521 - O09.529, O09.70 - O09.73, O09.811 - O09.819, O09.891 - O09.899, O09.90 - O09.93, Z11.59, Z32.01, Z33.1, Z33.3, Z34.00 - Z34.03, Z34.80 - Z34.83, Z34.90 - Z34.93, Z36.2, Z36.5, Z36.89, Z36.9 |
7. Hepatitis B ScreeningUSPSTF Recommendation: Recommends screening for hepatitis B virus (HBV) infection in pregnant women at their first prenatal visit. | Allpregnant women | 1 screening at the 1st prenatal visit | Hepatitis B screening will be covered for all pregnant women at the first prenatal visit. | None | 87340 80055 80081 | V22.0 V22.1 V22.2 V23.9 V28.0 V28.89 V28.9 V72.42 | O09.90 - O09.93, Z32.01, Z33.1, Z33.3, Z34.00 - Z34.03, Z34.80 - Z34.83, Z34.90 - Z34.93, Z36.2, Z36.5, Z36.89, Z36.9 |
High-risk pregnant women | Repeat screening at delivery Re-screen women with unknown status or new or continuing risk factors at admission to hospital/birth center | A second Hepatitis B screening may be conducted at admission to hospital/birth center according to documented risk factors by the healthcare provider. This is included within the hospital DRG. | Risk factors for a second hepatitis B screening include – Have unprotected sex with more than one partner Have unprotected sex with someone who's infected with HBV Have a sexually transmitted disease such as gonorrhea or chlamydia Share needles during intravenous (IV) drug use Share a household with someone who has a chronic HBV infection Have a job that exposes you to human blood Receive hemodialysis for end-stage kidney (renal) disease Travel to regions with high infection rates of HBV, such as Africa, Central and Southeast Asia, and Eastern Europe | ||||
8. HIV ScreeningUSPSTF Recommendation: Recommends that clinicians screen all pregnant women for human immunodeficiency virus (HIV), including those who present in labor who are untested and whose HIV status is unknown. | All pregnant women | 1 screening at the 1st prenatal visit | HIV screening will be covered for all pregnant women. The screening is to be conducted once during pregnancy. | None | 86701 86702 86703 87389 | V22.0 V22.1 V22.2 V23.0 V23.2 V23.49 V23.81 V23.82 V28.89 V28.9 V72.42 V23.85 V23.89 V23.9 V28.0 | O09.00 - O09.03, O09.291 - O09.299, O09.511 - O09.519, O09.521 - O09.529, O09.70 - O09.73, O09.811 - O09.819O 09.891 - O09.899 O09.90 - O09.93 Z32.01, Z33.1, Z33.3, Z34.00 - Z34.03, Z34.80 - Z34.83, Z34.90 - Z34.93, Z36.2, Z36.5, Z36.89, Z36.9 |
9. Rh (D) IncompatibilityUSPSTF Recommendation: Recommends Rh (D) blood typing and antibody testing for all pregnant women during their first visit for pregnancy-related care. | All pregnant women | 1 antibody testing at the 1st prenatal visit | Rh Incompatibility screening will be covered for all pregnant women. | None | 86901 86850 80055 80081 | V22.0 V22.1 V22.2 V23.2 V23.81 V23.9 V28.5 V28.89 V28.9 V72.42 | O09.291, O09.511 - O09.519, O09.90 - O09.93, Z29.13, Z32.01, Z33.1, Z33.3, Z34.00 - Z34.03, Z34.80 - Z34.83, Z34.90 - Z34.93, Z36.2, Z36.5, Z36.89, Z36.9 |
USPSTF Recommendation: The USPSTF recommends repeated Rh (D) antibody testing for all unsensitized Rh (D)-negative women at 24-28 weeks' gestation, unless the biological father is known to be Rh (D)-negative. | Unsensitized Rh (D)-negative pregnant women | Repeat antibody testing at 24-28 weeks’ gestation | Repeated Rh (D) antibody testing will be covered for all unsensitized Rh (D)-negative women at 24-28 weeks' gestation, unless the biological father is known to be Rh (D)-negative. | Unsensitized Rh (D)-negative women | 86901 86850 80055 80081 | V22.0 V22.1 V22.2 V23.2 V23.81 V23.9 V28.5 V28.89 V28.9 V72.42 | O09.291, O09.511 - O09.519, O09.90 - O09.93, Z29.13 Z32.01, Z33.1, Z34.00 - Z34.03, Z34.80 - Z34.83, Z34.90 - Z34.93, Z36.2, Z36.5, Z36.89, Z36.9 |
10. Bacteriuria ScreeningUSPSTF Recommendation: Recommends screening for asymptomatic bacteriuria with urine culture for pregnant women at 12 to 16 weeks' gestation or at the first prenatal visit, if later. | Allpregnant women | 1 screening per pregnancy | Bacteriuria screening will be covered for all pregnant women. The screening is to be conducted once during pregnancy, preferably at the first prenatal visit or 12-16 weeks gestation. | None | 87077 87084 87086 87088 | V22.0 V22.1 V22.2 V23.0 V23.2 V23.49 V23.81 V23.82 V23.85 V23.89 V23.9 V28.0 V28.4 V28.81 V28.89 V28.9 V72.42 | O09.00 - O09.03, O09.291 - O09.299, O09.511 - O09.519, O09.521 - O09.529, O09.70 - O09.73, O09.811 - O09.819, O09.891 - O09.899, O09.90 - O09.93, Z32.01, Z33.1, Z33.3, Z34.00 - Z34.03, Z34.80 - Z34.83, Z34.90 - Z34.93, Z36.2, Z36.5, Z36.89, Z36.9 |
11. Gestational Diabetes Mellitus (GDM) ScreeningUSPSTF Recommendation: Gestational diabetes mellitus screening at the first prenatal visit and between 24-28 weeks | Pregnant women identified to be at high risk for developing gestational diabetes mellitus | 1 screening at the 1st prenatal visit | Gestational diabetes screening will be covered at the first prenatal visit for pregnant women identified to be at high risk for developing diabetes mellitus | Risk factors for developing gestational diabetes mellitus include women who – Are obese Are older than 25 years Have a family history of diabetes Have a history of gestational diabetes mellitus Are of certain ethnic groups (Hispanic, Native American, South or East Asian, African-American or Pacific Island descent) | 82947 82948 82950 82962 | V22.0 V22.1 V22.2 V23.0 V23.1 V23.2 V23.3 V23.41 V23.42 V23.49 V23.5 V23.7 V23.81 V23.82 V23.83 V23.84 V23.85 V23.86 V23.87 V23.89 V23.9 V28.89 | O09.00 - O09.03, O09.10 - O09.13, O09.211 - O09.219, O09.291 - O09.299, O09.30 - O09.33, O09.40 - O09.43, O09.511 - O09.519, O09.521 - O09.529, O09.611 - O09.619, O09.70 - O09.73, O09.811 - O09.819, O09.821 - O09.829, O09.891 - O09.899, O09.90 - O09.93, O36.80X0 - O36.80X9, Z33.1, Z33.3, Z34.00 - Z34.03, Z34.80 - Z34.83, Z34.90 - Z34.93, Z36.2, Z36.5, Z36.89, Z36.9 |
All pregnant women | 1 screening between 24-28 weeks’ gestation | Gestational diabetes screening will be covered for all pregnant women between 24-28 weeks of pregnancy. | None | 82947 82948 82950 82962 | V22.0 V22.1 V22.2 V23.0 V23.1 V23.2 V23.3 V23.41 V23.42 V23.49 V23.5 V23.7 V23.81 V23.82 V23.83 V23.84 V23.85 V23.86 V23.87 V23.89 V23.9 | O09.00 - O09.03, O09.10 - O09.13 O09.211 - O09.219, O09.291 - O09.299, O09.30 - O09.33, O09.40 - O09.43, O09.511 - O09.519, O09.521 - O09.529, O09.611 - O09.619, O09.621 - O09.629, O09.811 - O09.819, O09.821 - O09.829, O36.80X0 - O36.80X9, O09.70 - O09.73, O09.891 - O09.899, O09.90 - O09.93, Z33.1, Z34.00 - Z34.03, Z34.80 - Z34.83, Z34.90 - Z34.93 | |
12. Folic Acid SupplementationUSPSTF Recommendation: Recommends that all women planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid. | Women planning or capable of pregnancy | 1 tablet per day by prescription | Folic acid supplementation may be covered at least 1 month before conception and may continue up to 3 months of pregnancy. Prescription is required. | Prescriptions will be required at the pharmacy to obtain folic acid supplements. | N/A | N/A | N/A |
13. Low-Dose Aspirin Use for the Prevention of Morbidity and Mortality From PreeclampsiaThe USPSTF recommends the use of low-dose aspirin (81 mg/d) as preventive medication after 12 weeks of gestation in women who are at high risk for preeclampsia. | Pregnant women identified to be at high risk for preeclampsia | One 81 mg aspirin tablet per day by prescription | One 81 mg aspirin tablet per day initiated between 12 and 28 weeks of gestation Prescription is required. | Pregnant women at high risk for preeclampsia include those with - History of preeclampsia, especially when accompanied by an adverse outcome Multifetal gestation Chronic hypertension Type 1 or 2 diabetes Renal disease Autoimmune disease (systemic lupus erythematous, antiphospholipid syndrome) Prescriptions will be required at the pharmacy to obtain aspirin. | N/A | N/A | N/A |
14. Prenatal Visit with PediatricianAAP Recommendation: A pediatric prenatal visit during the third trimester is recommended for all expectant families as an important first step in establishing a child's medical home | Expectant parents | 1 visit during the third trimester of pregnancy | One pediatric prenatal visit will be covered for expected parents per pregnancy. | Parents desiring to establish a trusted relationship and supportive medical home for their child as follows: First-time parents or parents who are new to the practice Single parents Women with a high-risk pregnancy or who are experiencing pregnancy complications or multiple gestations Parents whose previous pregnancies had a complication such as preterm delivery, an infant with a congenital anomaly, a prolonged course in the NICU, or a perinatal death | 99401 99402 99403 99404 | N/A | Z76.81 |
15. Screening for Diabetes Mellitus after Pregnancy HRSA Recommendation: Recommends screening for diabetes after birth in women who have a history of gestational diabetes and have not been previously diagnosed with type 2 diabetes. | After birth for all pregnant women with a history of gestational diabetes mellitus who have not been previously diagnosed with type 2 diabetes mellitus | 1 screening per calendar year | Diabetes screening will be covered for women who are not currently pregnant and who have not been previously diagnosed with type 2 diabetes mellitus | History of gestational diabetes without previous diagnosis of type 2 diabetes | 82947 82948 | N/A | Z86.32 O24.430 - O24.439 |
B. | Coverage of Preventive Health Services for Newborns | |||||
|---|---|---|---|---|---|---|
Service | Age/Sex | Interval/Limits | Policy | Risk Factors | Procedure Code(s) | Diagnosis Code(s) |
1. Hemoglobinopathy Screening (Sickle Cell Disease)HRSA Recommended Uniform Screening Panel Recommendation: Recommends screening for sickle cell disease in newborns. | All newborns | 1 screening | Hemoglobinopathy screening will be covered for all newborns. This is included within the hospital DRG. | None | N/A | N/A |
2. Congenital Hypothyroidism Screening HRSA Recommended Uniform Screening Panel Recommendation: Recommends screening for congenital hypothyroidism (CH) in newborns | All newborns | 1 screening | Congenital hypothyroidism screening will be covered for all newborns. This is included within the hospital DRG. | None | N/A | N/A |
3. PKU Screening HRSA Recommended Uniform Screening Panel Recommendation: Recommends screening for phenylketonuria (PKU) in newborns. | All newborns | 1 screening | PKU screening will be covered for all newborns. This is included within the hospital DRG. | None | N/A | N/A |
4. Newborn Hearing Screening AAP Recommendation: Recommends screening for hearing loss in all newborn infants. | All newborns | 1 screening | Newborn hearing screening will be covered for all newborns. This is included within the hospital DRG. | None | N/A | N/A |
5. Prophylactic Medication to Prevent Gonorrhea in Newborns USPSTF Recommendation: Recommends screening prophylactic ocular topical medication for all newborns against gonococcal ophthalmia neonatorum. | All newborns | 1 administration | Prophylactic medication to prevent Gonorrhea will be covered for all newborns. This is included within the hospital DRG. | None | N/A | N/A |
6. Critical Congenital Heart Defect Screening AAP Recommendation: Recommends screening for critical congenital heart disease using pulse oximetry should be performed in newborns, after 24 hours of age, before discharge from the hospital. | All newborns | 1 screening | Newborn congenital heart defect screening will be covered for all newborns. This is included within the hospital DRG. | None | N/A | N/A |
7. Newborn Outpatient Visit | Allnewborns | 1 visit | One outpatient visit will be covered for all newborns less than 8 days old for health examination and bilirubin check. | None | 99211 99381 99391 36415 36416 82247 82248 88720 | Z00.110 |
C. | Coverage of Preventive Health Services for Individuals Ages 0-21 Years | ||||||
|---|---|---|---|---|---|---|---|
Service | Age/Sex | Intervals/Limits | Policy | Risk Factors | Procedure Code(s) | ICD-9 Diagnosis Code(s) | ICD-10 Diagnosis Code(s) |
1. Lead ScreeningAAP Recommendation: Lead exposure assessment from ages 6 months-7 yrs. If the assessment indicates lead exposure, screening should be completed. | 6 months – 7 years | 0-9 screenings depending upon assessment | Lead screening will be covered for children at risk of lead exposure as documented by the healthcare provider. | Risk factors for increased blood lead levels include – minority race/ethnicity urban residence low income low educational attainment older (pre-1950) housing recent or ongoing home renovation or remodeling pica exposure use of ethnic remedies certain cosmetics, and exposure to lead-glazed pottery occupational and paraoccupational exposures recent immigration | 83655 | V15.86 V82.5 | Z13.88 Z77.011 |
2. TB TestingAAP Recommendation: TB exposure assessment from ages 1 month - 21 yrs. If the assessment indicates TB exposure, screening should be completed. | 1 month - 21 years | 0-24 screenings depending upon assessment | Covered as part of the Healthy You! preventive wellness visit | N/A | N/A | N/A | N/A |
3. Vision ScreeningAAP Recommendation: Vision screening to include visual acuity screening and opthalmoscopy for ocular assessment. | 3-18 years | 1 screening per year for a total of 9 screenings | Covered as part of the Healthy You! preventive wellness visit | N/A | N/A | N/A | N/A |
4. Hearing ScreeningAAP Recommendation: Hearing screening to include physical, subjective, and objective screening methods. | 3-21 years | 1 screening per year for a total of 6 screenings by 10 years of age 1 screening between 11-14 years of age 1 screening between 15-17 years of age 1 screening between 18-21 years of age | Covered as part of the Healthy You! preventive wellness visit | N/A | N/A | N/A | N/A |
5. Developmental ScreeningAAP Recommendation: Developmental screening to include milestones of motor, cognitive, and behavioral skills. | 9 months – 2.5 years | 3 screenings during the ages of 9 months - 2.5 years | Covered as part of the Healthy You! preventive wellness visit Developmental screening will be covered at 9 months, 18 months, and 2 years. | N/A | N/A | N/A | N/A |
6. Autism ScreeningAAP Recommendation: Autism screening to include subjective & objective assessment for autistic characteristics. | 18 months -2 years | 2 screenings during the ages of 18 months - 2 years. | Covered as part of the Healthy You! preventive wellness visit Autism screening will be covered at 18 months and 2 years. | N/A | N/A | N/A | N/A |
7. Depression ScreeningAAP Recommendation: Depression screening of adolescents (12-18 years of age) for major depressive disorder (MDD) when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal), and follow-up. USPSTF Recommendation:Recommends screening for major depressive disorder (MDD) in adolescents aged 12 to 18 years. Recommends screening for depression in the adult population, including pregnant and postpartum persons, as well as older adults. To achieve the benefit of depression screening and reduce disparities in depression-associated morbidity, it is important that persons who screen positive are evaluated further for diagnosis and, if appropriate, are provided or referred for evidence-based care. | 12-21 years | 1 per calendar year | Covered as part of the Healthy You! preventive wellness visit | N/A | N/A | N/A | N/A |
8. Anxiety in Children and Adolescents: Screening USPSTF Recommendation: Recommends screening for anxiety in children and adolescents aged 8 to 18 years. | 8-18 years | 1 screening and confirmatory diagnostic assessment per calendar year | Screening is covered as part of the Healthy You! preventive wellness benefits If screening test is positive for anxiety, one confirmatory diagnostic assessment will be covered. | N/A | 96127 | N/A | Z13.30 Z13.39 |
9. Chlamydia ScreeningUSPSTF Recommendation: Recommends screening for chlamydia in sexually activewomen age 24 years and younger and in older women who are at increased riskfor infection. | Sexually activewomen 24 and younger | 1 screening per calendar year | Chlamydia screening will be covered for all sexually active women ages 24 and younger. | All sexually active women 24 years of age or younger are at increased risk for chlamydial infection. | 87110 87270 87320 87490 87491 87492 87810 | V01.6 V01.79 V01.89 V01.9 V15.85 V15.89 V65.45 V69.2 V72.31 V72.41 V72.62 V72.69 V73.88 V73.89 V73.98 V73.99 V74.5V75.9 | Z00.00, Z01.411 - Z01.419, Z01.89, Z11.3, Z11.4, Z11.59, Z11.8, Z11.9, Z20.2, Z20.5 - Z20.6, Z20.828, Z20.89 Z20.9, Z32.02, Z57.8, Z71.89, Z72.51 - Z72.53, Z77.21 |
10. Syphilis ScreeningUSPSTF Recommendation: Recommends that clinicians screen persons at increased risk for syphilis infection. | Adolescents and adults who have ever been sexually active and are at increased risk for syphilis infection | 1 screening per calendar year | Syphilis screening will be covered for adolescents & adults at increased risk for syphilis infection. The screening may be conducted once per calendar year with documented risk factors by the healthcare provider. | Populations at increased risk for syphilis infection (as determined by incident rates) include - men who have sex with men persons with HIV or other sexually transmitted infections persons who use illicit drugs persons with history of incarceration, sex work, or military service | 86592 86593 | V01.6 V01.79 V01.89 V01.9 V15.85 V15.89 V65.45 V69.2 V72.31 V72.62 V72.69 V73.89 V73.99 V74.5 V75.9 V82.89 | Z00.00, Z01.411 - Z01.419, Z01.89, Z11.3, Z11.4, Z11.59, Z11.9, Z20.2, Z20.5 - Z20.6, Z20.828, Z20.89, Z20.9, Z71.89, Z72.51 - Z72.53, Z77.21 |
11. Gonorrhea ScreeningUSPSTF Recommendation: Recommends screening for gonorrhea in sexually active women age 24 years and younger and in older women who are at increased risk for infection. | Sexually active women age 24 years and younger | 1 screening per calendar year | Gonorrhea screening will be covered for all sexually active women 24 years of age and younger. | All sexually active women 24 years of age or younger are at increased risk for gonorrhea infection. | 87590 87591 87592 87850 | V01.6 V01.79 V01.89 V01.9 V15.85 V15.89 V65.45 V69.2 V72.62 V73.89 V72.31 V72.41 V72.69 V73.99 V74.5 V75.9 | Z00.00, Z01.411 - Z01.419, Z01.89, Z11.3, Z11.4, Z11.59, Z11.9, Z20.2, Z20.828, Z20.89, Z20.9, Z71.89, Z72.51 - Z72.53, Z32.02, Z77.21 |
12. HIV ScreeningUSPSTF Recommendation: Recommends that clinicians screen for HIV infection in adolescents and adults aged 15 to 65 years. Younger adolescents and older adults who are at increased risk should also be screened. | Sexually active adolescents and adults | 1 screening per calendar year | HIV screening will be covered for all sexually active adolescents and adults. | None | 86701 86702 86703 87389 | V70.0 (for sexually active women) V72.31 (for sexually active women) V01.6 V01.79 V01.89 V01.9 V15.85 V15.89 V65.45 V69.2 V73.89 V73.99 V74.5 | Z00.00 - Z00.01, Z01.411 - Z01.419, Z11.3, Z11.4, Z11.59, Z20.2, Z20.5 - Z20.6, Z20.828, Z20.89, Z20.9, Z57.8, Z71.89, Z72.51 - Z72.53, Z77.21 |
13. Iron SupplementationThe USPSTF recommends routine iron supplementation for asymptomatic children aged 6 to 12 months who are at increased risk for iron deficiency anemia | 6 – 12 months | N/A | Prescription strength iron supplements will be covered for children 6-12 months that are at increased risk of iron deficiency anemia. Prescription is required. | Prescriptions will be required at the pharmacy to obtain iron supplements. The healthcare provider must document anemia risk in the medical record. | N/A | N/A | N/A |
14. Fluoride SupplementationUSPSTF Recommendation: Recommends that primary care clinicians prescribe oral fluoride supplementation at currently recommended doses to preschool children older than 6 months of age whose primary water source is deficient in fluoride | 0 – 6 years | N/A | Prescription strength fluoride supplements will be covered for children 6 months and older that have a primary source of water that is deficient in fluoride. Prescription is required. | Prescriptions will be required at the pharmacy to obtain fluoride supplements. The healthcare provider must document in the medical record that the child’s primary source of water is deficient in fluoride. | N/A | N/A | N/A |
15. ImmunizationsCDC Recommendation: Recommends that immunizations & codes be applied as with Healthy You! | N/A | N/A | Covered under Healthy You! preventive wellness benefits | N/A | N/A | N/A | N/A |
16. Alcohol and Drug Use Assessment Recommends that primary care clinicians perform a yearly risk assessment beginning at age 9 | 9 years and older | N/A | Covered as part of the Healthy You! preventive wellness visit | N/A | N/A | N/A | N/A |
17. Dental Caries Prevention in Children Age 5 Years and Younger USPSTF Recommendation: Recommends that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption. | 0 - 5 years | 1 application per year | Application of fluoride varnish to the primary teeth of infants and children will be covered starting at the age of primary tooth eruption up to age 5. Prescription isrequired. | N/A | 99188 | V07.31 | Z41.8, Z29.3, Z91.841, Z91.842, Z91.843, Z91.849 |
18. Hepatitis B Virus Infection Screening: Non-Pregnant Adolescents and Adults USPSTF Recommendation: Recommends screening for hepatitis B virus (HBV) infection in asymptomatic, non-pregnant adolescents and adults who have not been vaccinated and other persons at high risk for hepatitis B virus (HBV) infection (including those at high risk who were vaccinated before being screened for HBV infection. | Adolescents and adults at increased risk for HBV infection | 1 screening per calendar year | Hepatitis B screening will be covered for adolescents and adults at increased risk for HBV infection. The screening may be conducted once per calendar year with documented risk factors by the healthcare provider. | Risk factors for HBV include - HIV-positive persons Injection drug users Household contacts or sexual partners of persons with HBV infection Men who have sex with men Persons receiving hemodialysis Persons receiving cytotoxic or immunosuppressive therapy Persons born in countries with a prevalence of HBV infection of 2% or greater Lack of vaccination in infancy in U.S.-born persons with parents from a country or region with high prevalence (≥8%), such as sub-Saharan Africa, central and southeast Asia, and China. | 87340 G0499 | V01.89 | Z20.89 |
19. Latent Tuberculosis Screening: Adults USPSTF Recommendation: Recommends screening for latent tuberculosis (TB) infection in populations at increased risk. | Asymptomatic adults at increased risk | 1 screening per calendar year | Latent tuberculosis screening will be covered for adults at increased risk for TB infection. The screening may be conducted once per calendar year with documented risk factors by the healthcare provider. | Risk factors for latent tuberculosis include - Persons born in, or former residents of, countries with increased tuberculosis prevalence; and Persons who live in, or have lived in, high-risk congregate settings (eg, homeless shelters & correctional facilities) | 86480 86481 | N/A | Z11.1 Z11.7 Z20.1 |
20. Oral Health Risk Assessment AAP Recommendation: Recommends pediatricians should assess whether the child has a dental home beginning at age 6 months. If no dental home is identified, the pediatrician should perform a risk assessment, refer to a dental home and recommend brushing with fluoride toothpaste in the proper dosage for age. | 6 months and older | N/A | An oral health risk assessment will be covered for children 6 months and older. Covered as part of the Healthy You! preventive wellness visit | N/A | N/A | N/A | N/A |
21. Prevention of Human Immunodeficiency Virus (HIV) Infection: Preexposure ProphylaxisUSPSTF Recommendation: Recommends that clinicians offer preexposure prophylaxis (PrEP) with effective antiretroviral therapy to persons who are at high risk of HIV acquisition. | Adults and adolescents weighing at least 35 kg | 1 tablet per day by prescription | One generic tablet per day containing 200 mg of emtricitabine and 300 mg of tenofovir disoproxil fumarate will be covered for persons who are not infected with HIV as evidenced by a recently documented negative HIV test and are at high risk of HIV infection Prescription is required. | • Men who have sex with men, are sexually active, and have one of the following characteristics: In a sexual relationship with a partner living with HIV Inconsistent use of condoms during receptive or insertive anal sex A sexually transmitted infection (STI) with syphilis, gonorrhea, or chlamydia within the past 6 months • Heterosexually active women and men who have one of the following characteristics: In a sexual relationship with a partner living with HIV Inconsistent use of condoms during sex with a partner whose HIV status is unknown and who is at high risk (eg, a person who injects drugs or a man who has sex with men and women) An STI with syphilis or gonorrhea within the past 6 months • Persons who inject drugs and have one of the following characteristics: Shared use of drug injection equipment Risk of sexual acquisition of HIV • Persons who engage in transactional sex, such as sex for money, drugs, or housing • Commercial sex workers or persons trafficked for sex work • Transgender women and men who are sexually active HIV screening tests should be repeated at least every 3 months. See E.19 for details of PrEP initiation and ongoing monitoring. | N/A | N/A | Z20.2, Z20.6, Z20.828, Z20.89, Z20.9, Z29.81, Z57.8, Z72.51, Z72.52, Z72.53, Z77.21 |
22. Unhealthy Drug Use: ScreeningUSPSTF Recommendation: Recommends screening by asking questions about unhealthy drug use in adults age 18 years or older. Screening should be implemented when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred. (Screening refers to asking questions about unhealthy drug use, not testing biological specimens.) | 18 years and older | N/A | Covered as part of the Healthy You! preventive wellness visit | N/A | N/A | N/A | N/A |
D. | Coverage of Preventive Health Services for Women 21 Years and Older | ||||||
|---|---|---|---|---|---|---|---|
Service | Age/Sex | Interval/Limits | Policy | Risk Factors | Procedure Code(s) | ICD-9 Diagnosis Code(s) | ICD-10 Diagnosis Code(s) |
1. Chlamydia ScreeningUSPSTF Recommendation: Recommends screening for chlamydia in sexually active women age 24 years and younger and in older women who are at increased risk for infection. | Sexually active women 24 and younger | 1 screening per calendar year | Chlamydia screening will be covered for all sexually active women ages 24 and younger. | All sexually active women 24 years of age or younger are at increased risk for chlamydial infection. | 87110 87270 87320 87490 87491 87492 87810 | V01.6 V01.79 V01.89 V01.9 V15.85 V15.89 V65.45 V69.2 V72.31 V72.41 V72.62 V72.69 V73.88 V73.89 V73.98 V73.99 V74.5 V75.9 | Z00.00, Z01.411 - Z01.419, Z01.89, Z11.3, Z11.4, Z11.59, Z11.8, Z11.9, Z20.2, Z20.5 - Z20.6, Z20.828, Z20.89, Z20.9, Z32.02, Z57.8, Z71.89, Z72.51 - Z72.53, Z77.21 |
Women 25 and older who are at increased risk | 1 screening per calendar year | Chlamydia screening may be conducted once per calendar year for women ages 25 and older with documented risk factors by the healthcare provider. | In addition to sexual activity and age, other risk factors for chlamydial infection include - a history of chlamydial or other sexually transmitted infection new or multiple sexual partners inconsistent condom use exchanging sex for money or drugs a sex partner with concurrent partner a sex partner with a sexually transmitted infection | 87110 87270 87320 87490 87491 87492 87810 | V69.2 | Z72.51 - Z72.53 | |
2. Syphilis ScreeningUSPSTF Recommendation: Recommends that clinicians screen persons at increased risk for syphilis infection. | Women who have ever been sexually active and are at increased risk for syphilis infection | 1 screening per calendar year | Syphilis screening will be covered for adolescents & adults at increased risk for syphilis infection. The screening may be conducted once per calendar year with documented risk factors by the healthcare provider. | Syphilis screening will be covered for adolescents & adults at increased risk for syphilis infection. Populations at increased risk for syphilis infection (as determined by incident rates) include - persons with HIV or other sexually transmitted infections persons who use illicit drugs persons with history of incarceration, sex work, or military service | 86592 86593 | V01.6 V01.79 V01.89 V01.9 V15.85 V15.89 V65.45 V69.2 V72.31 V72.62 V72.69 V73.89 V73.99 V74.5 V75.9 V82.89 | Z00.00, Z01.411 - Z01.419, Z01.89, Z11.3, Z11.4, Z11.59, Z11.9, Z20.2, Z20.5 - Z20.6, Z20.828, Z20.89, Z20.9, Z57.8, Z71.89, Z72.51 - Z72.53, Z77.21 |
3. Gonorrhea ScreeningUSPSTF Recommendation: Recommends screening for gonorrhea in sexually active women age 24 years and younger and in older women who are at increased risk for infection. | Sexually active women 24 years and younger who are at increased risk | 1 screening per calendar year | Gonorrhea screening will be covered for females 24 years of age and younger. | All sexually active women 24 years of age or younger are at increased risk for gonorrhea infection. | 87590 87591 87592 87850 | V01.6 V01.79 V01.89 V01.9 V15.85 V15.89 V65.45 V69.2 V72.62 V73.89 V72.31 V72.41 V72.69 V73.99 V74.5 V75.9 | Z00.00, Z01.411 - Z01.419, Z01.89, Z11.3 Z11.4, Z11.59, Z11.9, Z20.2, Z20.5 - Z20.6, Z20.828, Z20.89, Z20.9, Z32.02, Z57.8, Z71.89, Z72.51 - Z72.53, Z77.21 |
Women 25 and older who are at increased risk | 1 screening per calendar year | Gonorrhea screening may be conducted once per calendar year for women ages 25 and older with documented risk factors by the healthcare provider. | In addition to sexual activity and age, other risk factors for gonorrhea include - a history of previous gonorrhea infection other sexually transmitted infections new or multiple sexual partners inconsistent condom use sex work drug use a sex partner with concurrent partners a sex partner with a sexually transmitted infection | 87590 87591 87592 87850 | V01.6 V01.79 V01.89 V01.9 V15.85 V15.89 V65.45 V69.2 V72.62 V73.89 V72.31 V72.41 V72.69 V73.99 V74.5 V75.9 | Z00.00, Z01.411 - Z01.419, Z01.89, Z11.3 Z11.4, Z11.59, Z11.9, Z20.2, Z20.5 - Z20.6, Z20.828, Z20.89, Z20.9, Z32.02, Z57.8, Z71.89, Z72.51 - Z72.53, Z77.21 | |
4. HIV ScreeningUSPSTF Recommendation: Recommends that clinicians screen for HIV infection in adolescents and adults aged 15 to 65 years. Younger adolescents and older adults who are at increased risk should also be screened. | All sexually active women | 1 screening per calendar year | HIV screening will be covered for all sexually active women. | None | 86701 86702 86703 87389 | V70.0 V72.31 V73.89 | Z00.00 - Z00.01, Z01.411 - Z01.419, Z11.4 |
5. Risk Assessment, Genetic Counseling and Genetic Testing for BRCA-Related CancerUSPSTF Recommendation: Recommends that primary care clinicians assess women with a personal or family history of breast, ovarian, tubal, or peritoneal cancer or who have an ancestry associated with breast cancer susceptibility 1 and 2 (BRCA1/2) gene mutations with an appropriate brief familial risk assessment tool. Women with a positive result on the risk assessment tool should receive genetic counseling and, if indicated after counseling, genetic testing. | Females age 18 and over with a personal history, family history, or ancestry associated with an increased risk for harmful mutations in BRCA1/2 genes. | 1 per lifetime | BRCA assessment and counseling will be covered for women with a personal or family history of breast, ovarian, tubal, or peritoneal cancer or who have an ancestry associated with BRCA1/2 gene mutation. BRCA testing will be covered for women with positive results per the Genetic Testing for BRCA1 or BRCA2 for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers medical policy. | Criteria for increased risk for harmful mutations in BRCA1/2 genes are outlined in the Genetic Testing for BRCA1 or BRCA2 for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers medical policy. | 81162 81163 81164 81165 81166 81167 81212 81215 81216 81217 | V16.3 V84.01 V84.02 | Z15.01 Z15.02 Z15.09 Z80.0 Z80.3 Z80.41 Z80.49 Z80.8 Z85.068 Z85.09 Z85.3 Z85.43 Z85.49 |
6. Folic Acid SupplementationUSPSTF Recommendation: Recommends that all women planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid. | Women planning or capable of pregnancy | 1 tablet per day by prescription | Folic acid supplementation may be covered at least 1 month before conception and may continue up to 3 months of pregnancy. Prescription is required. | Prescriptions will be required at the pharmacy to obtain folic acid supplements. | N/A | N/A | N/A |
7. Depression ScreeningUSPSTF Recommendation: Recommends screening for depression in the adult population, including pregnant and postpartum persons, as well as older adults. To achieve the benefit of depression screening and reduce disparities in depression-associated morbidity, it is important that persons who screen positive are evaluated further for diagnosis and, if appropriate, are provided or referred for evidence-based care. | N/A | N/A | Covered as part of the Healthy You! preventive wellness visit | N/A | N/A | N/A | N/A |
8. Hepatitis B Virus Infection Screening: Non-Pregnant Adolescents and Adults USPSTF Recommendation: Recommends screening for hepatitis B virus (HBV) infection in asymptomatic, non-pregnant adolescents and adults who have not been vaccinated and other persons at high risk for hepatitis B virus (HBV) infection (including those at high risk who were vaccinated before being screened for HBV infection. | Adolescents and adults at increased risk for HBV infection | 1 screening per calendar year | Hepatitis B screening will be covered for adolescents and adults at increased risk for HBV infection. The screening may be conducted once per calendar year with documented risk factors by the healthcare provider. | Risk factors for HBV include - HIV-positive persons Injection drug users Household contacts or sexual partners of persons with HBV infection Men who have sex with men Persons receiving hemodialysis Persons receiving cytotoxic or immunosuppressive therapy Persons born in countries with a prevalence of HBV infection of 2% or greater Lack of vaccination in infancy in U.S.-born persons with parents from a country or region with high prevalence (≥8%), such as sub-Saharan Africa, central and southeast Asia, and China. | 87340 G0499 | V01.89 | Z20.89 |
9. Hepatitis C Virus Infection Screening: Adults USPSTF Recommendation: Recommends screening for hepatitis C virus (HCV) infection in adults aged 18 to 79 years. | Asymptomatic adults without known liver disease | 1 time screening for asymptomatic adults 1 screening per calendar year for adults at continued high risk for HCV | One screening will be covered for asymptomatic adults. The screening may be conducted once per calendar year for adults with documented risk factors by the healthcare provider. | Risk factors for HCV include – Past or current injection drug use Receipt of a blood transfusion before 1992 Long-term hemodialysis Being born to an HCV-infected mother Incarceration Intranasal drug use Getting an unregulated tattoo Other percutaneous exposures (such as in health care workers or from having surgery before the implementation of universal precautions). | 86803 | V01.89 | Z20.89 |
10. Urinary Incontinence Screening HRSA Recommendation: Recommends screening women for urinary incontinence annually to assess whether women experience urinary incontinence and whether it impacts their activities and quality of life. Women should be referred for further evaluation and treatment if indicated. | All women | N/A | Covered as part of the Healthy You! preventive wellness visit | N/A | N/A | N/A | N/A |
E. | Coverage of Preventive Health Services for High Risk Population Ages 21 Years and Older | ||||||
|---|---|---|---|---|---|---|---|
Service | Age/Sex | Intervals/Limits | Policy | Risk Factors | Procedure Code(s) | ICD-9 Diagnosis Code(s) | ICD-10 Diagnosis Code(s) |
1. Screening for AbdominalAortic AneurysmUSPSTF Recommendation: Recommends one-time screening for abdominal aortic aneurysm (AAA) by ultrasonography in men aged 65 to 75 who have ever smoked. | Men aged 65 to 75 who have ever smoked | 1 screening per lifetime | Abdominal Aortic Aneurysm screening will be covered for men at increased risk, defined as 65 and greater with a history of smoking | Men who have smoked at least 100 cigarettes in their lifetime. | G0389 76705 76706 76770 76775 76700 | V15.82 V81.2 | Z13.6 Z87.891 |
2. Syphilis ScreeningUSPSTF Recommendation: Recommends that clinicians screen persons at increased risk for syphilis infection. | Adults who have ever been sexually active and are at increased risk for syphilis infection | 1 screening per calendar year | Syphilis screening will be covered for adolescents & adults at increased risk for syphilis infection. The screening may be conducted once per calendar year with documented risk factors by the healthcare provider. | Populations at increased risk for syphilis infection (as determined by incident rates) include – men who have sex with men persons with HIV or other sexually transmitted infections persons who use illicit drugs persons with history of incarceration, sex work, or military service | 86592 86593 | V01.6 V01.79 V01.89 V01.9 V15.85 V15.89 V65.45 V69.2 V72.31 V72.62 V72.69 V73.89 V73.99 V74.5 V75.9 V82.89 | Z00.00, Z01.411 - Z01.419, Z01.89, Z11.3, Z11.4, Z11.59 Z11.9, Z20.2, Z20.5 - Z20.6, Z20.828, Z20.89 Z20.9, Z57.8, Z71.89, Z72.51 - Z72.53, Z77.21 |
3. HIV ScreeningUSPSTF Recommendation: Recommends that clinicians screen for HIV infection in adolescents and adults aged 15 to 65 years. Younger adolescents and older adults who are at increased risk should also be screened. | All sexually active adolescents and adults | 1 screening per calendar year | HIV screening will be covered for all sexually active adolescents and adults. | None | 86701 86702 86703 87389 | V70.0 (for sexually active women) V72.31 (for sexually active women) V01.6 V01.79 V01.89 V01.9 V15.89 V15.85 V65.44 V65.45 V69.2 V73.89 V73.99 V74.5 V75.9 | Z00.00 - Z00.01, Z01.411 - Z01.419, Z11.3, Z11.4, Z11.59, Z20.2, Z20.5 - Z20.6, Z20.828, Z20.89 Z20.9, Z57.8, Z71.89, Z72.51 - Z72.53, Z77.21 |
4. Aspirin Use to Prevent Cardiovascular Disease and Colorectal CancerUSPSTF Recommendation: Recommends initiating low-dose aspirin use for the primary prevention of cardiovascular (CVD) and colorectal cancer (CRC) in adults aged 50 to 59 years at risk. | Adults age 50 to 59 years | One 81 mg aspirin tablet per day by prescription | One 81 mg aspirin tablet per day will be covered for adults with documented risk factors by the healthcare provider. Prescription is required. | All of the following must be documented: Have a 10% or greater 10-year CVD risk Are not at increased risk for bleeding Have a life expectancy of at least 10 years Are willing to take low-dose aspirin daily for at least 10 years. | N/A | N/A | N/A |
5. Depression ScreeningUSPSTF Recommendation: Recommends screening for depression in the adult population, including pregnant and postpartum persons, as well as older adults. To achieve the benefit of depression screening and reduce disparities in depression-associated morbidity, it is important that persons who screen positive are evaluated further for diagnosis and, if appropriate, are provided or referred for evidence-based care. | N/A | N/A | Covered as part of the Healthy You! preventive wellness visit | N/A | N/A | N/A | N/A |
6. ImmunizationsCDC Recommendation: Recommends that immunizations & codes be applied as with Healthy You! | N/A | N/A | Covered under Healthy You! preventive wellness benefits | N/A | N/A | N/A | N/A |
7. Hepatitis B Virus Infection Screening: Non-Pregnant Adolescents and Adults USPSTF Recommendation: Recommends screening for hepatitis B virus (HBV) infection in asymptomatic, non-pregnant adolescents and adults who have not been vaccinated and other persons at high risk for hepatitis B virus (HBV) infection (including those at high risk who were vaccinated before being screened for HBV infection. | Adolescents and adults at increased risk for HBV infection | 1 screening per calendar year | Hepatitis B screening will be covered for adolescents and adults at increased risk for HBV infection. The screening may be conducted once per calendar year with documented risk factors by the healthcare provider. | Risk factors for HBV include - HIV-positive persons Injection drug users Household contacts or sexual partners of persons with HBV infection Men who have sex with men Persons receiving hemodialysis Persons receiving cytotoxic or immunosuppressive therapy Persons born in countries with a prevalence of HBV infection of 2% or greater Lack of vaccination in infancy in U.S.-born persons with parents from a country or region with high prevalence (≥8%), such as sub-Saharan Africa, central and southeast Asia, and China. | 87340 G0499 | V01.89 | Z20.89 |
8. Hepatitis C Virus Infection Screening: Adults USPSTF Recommendation: Recommends screening for hepatitis C virus (HCV) infection in adults aged 18 to 79 years. | Asymptomatic adults without known liver disease | 1 time screening for asymptomatic adults 1 screening per calendar year for adults at continued high risk for HCV | One screening will be covered for asymptomatic adults. The screening may be conducted once per calendar year for adults with documented risk factors by the healthcare provider. | Risk factors for HCV include – Past or current injection drug use Receipt of a blood transfusion before 1992 Long-term hemodialysis Being born to an HCV-infected mother Incarceration Intranasal drug use Getting an unregulated tattoo Other percutaneous exposures (such as in health care workers or from having surgery before the implementation of universal precautions). | 86803 | V01.89 | Z20.89 |
9. Lung Cancer Screening USPSTF Recommendation: Recommends annual screening for lung cancer with low-dose computed tomography in adults ages 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery. | Adults ages 50 to 80 at risk for lung cancer | 1 screening per calendar year | Low-dose computed tomography (CT) scanning will be covered as a screening technique for lung cancer in high risk individuals. | ALL of the following criteria must be met: Between 50 and 80 years of age History of cigarette smoking of at least 20 pack-years If former smoker, quit within the previous 15 years | 71271 | V76.0 | Z12.2 |
10. Osteoporosis Screening: Women USPSTF Recommendation: Recommends screening for osteoporosis in women age 65 years and older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors. | Women age 65 and older | 1 per lifetime | Covered under Healthy You! preventive wellness benefits | N/A | N/A | N/A | N/A |
11. Breast Cancer Preventive Medication USPSTF Recommendation:Recommends that clinicians offer to prescribe risk-reducing medications, such as tamoxifen, raloxifene, or aromatase inhibitors,to women who are at increased risk for breast cancer and at low risk for adverse medication effects, | Women 35 and older who are at increased risk | 1 tablet per day by prescription | Tamoxifen or raloxifene may be considered medically necessary to reduce the risk of primary breast cancer development in women who meet ALL of the criteria in the Risk-Reducing Medications for Primary Breast Cancer: Tamoxifen and Raloxifenemedical policy. | Refer to the Risk-Reducing Medications for Primary Breast Cancer medical policy. | N/A | V84.01 | Z15.01 |
12. Falls Prevention in Older Adults: Exercise or Physical Therapy USPSTF Recommendation: Recommends exercise or physical therapy to prevent falls in community-dwelling adults age 65 years and older who are at increased risk for falls. | 65 and older when BCBSMS is the primary payer | 1 physical therapy session | One physical therapy session will be covered at the Allied Specialist’s office or facility to develop an exercise program to address balance, strength, and gait training for community-dwelling adults age 65 years or older with a history of falls (history of falls is defined as 2 or more falls in the past year or any fall with injury in the past year) | The healthcare provider must document the history of falls in the medical record. | 97110 97112 97116 97163 | V15.88 | Z91.81 |
13. Falls Prevention in Older Adults: Vitamin D USPSTF Recommendation: Recommends Vitamin D supplementation to prevent falls in community-dwelling adults age 65 years and older who are at increased risk for falls. | 65 and older when BCBSMS is the primary payer | 1 tablet per day by prescription | Vitamin D supplementation will be covered for community-dwelling adults age 65 years or older with a history of falls (history of falls is defined as 2 or more falls in the past year or any fall with injury in the past year) Prescription is required. | Prescriptions will be required at the pharmacy to obtain Vitamin D. The healthcare provider must document the history of falls in the medical record. | N/A | V15.88 | Z91.81 |
14. Latent Tuberculosis Screening: Adults USPSTF Recommendation: Recommends screening for latent tuberculosis (TB) infection in populations at increased risk. | Asymptomatic adults at increased risk | 1 screening per calendar year | Latent tuberculosis screening will be covered for adults at increased risk for TB infection. The screening may be conducted once per calendar year with documented risk factors by the healthcare provider. | Risk factors for latent tuberculosis include - Persons born in, or former residents of, countries with increased tuberculosis prevalence; and Persons who live in, or have lived in high-risk congregate settings (eg, homeless shelters & correctional facilities). | 86480 86481 | N/A | Z11.1 Z11.7 Z20.1 |
15. Colorectal Cancer Screening: Stool DNA Testing (Cologuard or Cologuard Plus) USPSTF Recommendation: Recommends screening for colorectal cancer starting at age 45 years and continuing until age 75 years. | Asymptomatic adults aged 45 to 75 | 1 screening every 3 years | Fecal DNA Testing (Cologuard or Cologuard Plus) will be covered for asymptomatic adults aged 45 to 75 at average risk for developing colorectal cancer who meet ALL of the criteria in the Analysis of Human DNA in Stool Samples as a Technique for Colorectal Cancer Screening medical policy. | N/A | 81528 0464U | N/A | Z12.10 Z12.11 Z12.12 Z12.13 |
16. Colorectal Cancer Screening: Fecal Occult Blood Test (FOBT) USPSTF Recommendation: Recommends screening for colorectal cancer starting at age 45 years and continuing until age 75 years. | Asymptomatic adults aged 45 to 75 | 1 screening for calendar year | Screening for colorectal cancer using high-sensitivity FOBT will be covered once per year for adults aged 45 to 75. | N/A | 82270 82274 G0328 | N/A | Z12.10 Z12.11 Z12.12 Z12.13 |
17. Colorectal Cancer Screening: Follow-Up ColonoscopyUSPSTF Recommendation: The USPSTF recommends screening for colorectal cancer in adults aged 45 to 75 years. For screening benefits to be achieved, abnormal findings identified by a direct visualization test or positive results on a stool-based screening test require follow-up with colonoscopy. | Adults aged 45 to 75 | 1 follow-up colonoscopy every 10 years | To complete screening benefits, one timely colonoscopy (performed within 6 months) will be covered to follow up on positive results or abnormal findings identified by Fecal DNA Testing (Cologuard), high-sensitivity FOBT, or flexible sigmoidoscopy. | N/A | G0105 G0121 44388 44389 44392 44394 44401 45378 45380 45381 45384 45385 45388 45390 | N/A | R19.5 Z12.10 Z12.11 Z12.12 |
18. Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: Preventive Medication USPSTF Recommendation: Recommends adults without a history of cardiovascular disease (CVD) (ie, symptomatic coronary artery disease or ischemic stroke) use a low- to moderate-dose statin for the prevention of CVD events and mortality when certain criteria are met. | Adults aged 40 to 75 years without a history of CVD | As prescribed | One of the following statin medications will be covered as prescribed: Simvastatin Tab 10MG Lovastatin Tab 20mg Lovastatin Tab 40mg Prescription is required. | The following risk factors must be documented by the healthcare provider: Have one or more CVD risk factors (ie, dyslipidemia, diabetes, hypertension, or smoking), AND Have a calculated 10-year risk of a cardiovascular event of 10% or greater | N/A | N/A | N/A |
19. Prevention of Human Immunodeficiency Virus (HIV) Infection: Pre-Exposure ProphylaxisUSPSTF Recommendation: Recommends that clinicians offer pre-exposure prophylaxis (PrEP) with effective antiretroviral therapy to persons who are at high risk of HIV acquisition. Before prescribing PrEP, clinicians should exclude persons with acute or chronic HIV infection through taking a medical history and HIV testing. It is also generally recommended that kidney function testing, serologic testing for hepatitis B and C virus, testing for other STIs, and pregnancy testing (when appropriate) be conducted at the time of or just before initiating PrEP. Ongoing follow-up and monitoring, including HIV testing every 3 months, is also suggested. | Adults and adolescents weighing at least 35 kg | 1 tablet per day by prescription | One tablet per day containing 200 mg of emtricitabine and 300 mg of tenofovir disoproxil fumarate will be covered for persons who are not infected with HIV as evidenced by a recently documented negative HIV test and are at high risk of HIV infection. Prescription is required. | • Men who have sex with men, are sexually active, and have one of the following characteristics: In a sexual relationship with a partner living with HIV Inconsistent use of condoms during receptive or insertive anal sex A sexually transmitted infection (STI) with syphilis, gonorrhea, or chlamydia within the past 6 months • Heterosexually active women and men who have one of the following characteristics: In a sexual relationship with a partner living with HIV Inconsistent use of condoms during sex with a partner whose HIV status is unknown and who is at high risk (eg, a person who injects drugs or a man who has sex with men and women) An STI with syphilis or gonorrhea within the past 6 months • Persons who inject drugs and have one of the following characteristics: Shared use of drug injection equipment Risk of sexual acquisition of HIV • Persons who engage in transactional sex, such as sex for money, drugs, or housing • Commercial sex workers or persons trafficked for sex work • Transgender women and men who are sexually active HIV screening tests should be repeated at least every 3 months. | G0011 G0012 G0013 | N/A | Z11.3 Z11.4 Z11.59 Z20.2 Z20.5 Z20.6 Z20.828 Z20.89 Z20.9 Z29.81 Z57.8 Z71.7 Z72.51 Z72.52 Z72.53 Z77.21 |
Before PrEP initiation | Office visit for assessment and PrEP education HIV testing Chlamydia, gonorrhea, and syphilis testing Hepatitis B and C virus testing Pregnancy testing and pregnancy intent Kidney function testing Sexually transmitted infection counseling (Refer to section F.7 of this policy) | Adults and adolescents offered PrEP | 99401 99402 99403 99404 86701 86702 86703 87389 87110 87270 87320 87490 87491 87492 87590 87591 87592 87850 87810 86592 86593 87340 G0499 86803 81025 84702 84703 82565 G0445 | ||||
Follow-up every 3 months after PrEP initiation | Office visit for assessment, monitoring, and adherence counseling and support HIV testing Chlamydia, gonorrhea, and syphilis testing in individuals with signs or symptoms of a STI or at high risk for STI infection Pregnancy testing and pregnancy intent | Adults and adolescents prescribed PrEP | 99401 99402 99403 99404 86701 86702 86703 87389 87110 87270 87320 87490 87491 87492 87590 87591 87592 87850 87810 86592 86593 81025 84702 84703 | ||||
Follow-up every 6 months after PrEP initiation | Office visit for assessment, monitoring, and adherence counseling and support Chlamydia, gonorrhea, and syphilis testing without signs or symptoms of a STI and not at high risk for STI infection Kidney function testing Hepatitis B DNA test for PrEP users with chronic hepatitis B infection Sexually transmitted infection counseling (Refer to section F.7 of this policy) | Adults and adolescents prescribed PrEP | 99401 99402 99403 99404 87110 87270 87320 87490 87491 87492 87590 87591 87592 87850 87810 86592 86593 82565 87516 87517 G0445 | ||||
20. Unhealthy Drug Use: Screening USPSTF Recommendation: Recommends screening by asking questions about unhealthy drug use in adults age 18 years or older. Screening should be implemented when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred. (Screening refers to asking questions about unhealthy drug use, not testing biological specimens.) | 18 years and older | N/A | Covered as part of the Healthy You! preventive wellness visit | N/A | N/A | N/A | N/A |
F. | Other Preventive Services | |||||
|---|---|---|---|---|---|---|
Service | Age/Sex | Interval/Limits | Policy | Risk Factors | Procedure Code(s) | Diagnosis Code(s) |
1. Interventions for Tobacco Use Cessation: Pregnant Women USPSTF Recommendation: Recommends that clinicians ask all pregnant women about tobacco use, advise them to stop using tobacco, and provide behavioral interventions for cessation to pregnant women who use tobacco | All pregnant women | N/A | Covered as part of the Healthy You! preventive wellness benefits Counseling covered as part of the Be Tobacco-free program | N/A | N/A | N/A |
2. Prevention and Cessation of Tobacco Use in Children and Adolescents: Primary Care Interventions USPSTF Recommendation: Recommends primary care clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use among school-aged children and adolescents. | 6-17 years | N/A | Covered as part of the Healthy You! preventive wellness benefits For adolescents 16 years and older, counseling covered as part of the Be Tobacco-free program with parental consent | N/A | N/A | N/A |
3. Interventions for Tobacco Use Cessation: Non-Pregnant Adults USPSTF Recommendation: Recommends that clinicians ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and U.S. Food and Drug Administration (FDA)-approved pharmacotherapy for cessation to non-pregnant adults who use tobacco. | 18 and older | N/A | Covered as part of the Healthy You! preventive wellness visit Counseling and FDA-approved pharmacotherapy for cessation covered as part of the Be Tobacco-free program | N/A | N/A | N/A |
4. Unhealthy Alcohol Use Counseling- Pregnancy, Adults 18+ USPSTF Recommendation: Recommends screening for unhealthy alcohol use in primary care settings in adults 18 years or older, including pregnant women, and providing persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce unhealthy alcohol use. | All pregnant women and adults 18 years and older | N/A | Covered as part of the Healthy You! preventive wellness visit | N/A | N/A | N/A |
5. Obesity in Children and Adolescents: Screening USPSTF Recommendation: Recommends that clinicians screen children aged 6 years and older for obesity and offer or refer them to comprehensive, intensive behavioral interventions to promote improvement in weight status. | 6 – 17 years | 3 hours per calendar year | Screening covered as part of the Healthy You! preventive wellness visit Three hours of behavioral counseling for obesity with a Primary Care Provider (PCP) will be covered. | BMI at or above the 95th percentile on the sex-and age-specific Centers for Disease Control and Prevention (CDC) growth chart | G0447, Face-to- face behavioral counseling for obesity, 15 minutes | Z68.54, Z68.55, Z68.56 (Z68.55, Z68.56 New 10/01/2024) |
6. Weight Loss to Prevent Obesity-Related Morbidity and Mortality in Adults: Behavioral Interventions USPSTF Recommendation: Recommends that clinicians offer or refer adults with a body mass index (BMI) of 30 or higher to intensive, multicomponent behavioral interventions. | 18 years and older | 3 hours per calendar year | Three hours of behavioral counseling for obesity with a Primary Care Provider (PCP) will be covered. | BMI of 30 or higher | G0447, Face-to- face behavioral counseling for obesity, 15 minute | Z68.30 – Z68.45, BMI code range, adult |
7. Behavioral Counseling Interventions to Prevent Sexually Transmitted Infections USPSTF Recommendation: Recommends behavioral counseling for all sexually active adolescents and for adults at increased risk for STIs. | All sexually active adolescents and adults at increased risk | 2 sessions per calendar year | Two counseling sessions per calendar year with a Primary Care Provider (PCP) will be covered for all sexually active adolescents and adults at increased risk sexually transmitted infections. | Risk factors for STIs include - being diagnosed with an STI within the past year, having multiple sex partners or having a partner(s) at high risk for STIs not consistently using condoms belonging to a population that has a high STI prevalence persons seeking STI testing or attending an STI clinic sexual and gender minorities persons living with HIV persons with injection drug use persons who exchange sex for money or drugs persons who have recently been in a correctional facility some racial/ethnic minority groups | G0445, Semiannual high intensity behavioral counseling to prevent STIs, individual, face-to- face, includes education skills training & guidance on how to change sexual behavior | Z20.2 Z20.6 Z20.828 Z20.89 Z20.9 Z57.8 Z72.51 Z72.52 Z72.53 Z77.21 |
8. Behavioral Health Counseling Interventions to Promote a Healthy Diet and Physical Activity for Cardiovascular Disease Prevention in Adults with Cardiovascular Risk Factors USPSTF Recommendation: Recommends offering or referring adults with cardiovascular disease (CVD) risk factors to behavioral counseling interventions to promote a healthful diet and physical activity. | Adults with risk factors for cardiovascular disease | 6 hours per calendar year | Six hours of behavioral counseling per calendar year with a Primary Care Provider (PCP) will be covered for all adults with one or more cardiovascular risk factors. | Risk factors for CVD include – known hypertension or elevated blood pressure dyslipidemia mixed or multiple risk factors such as metabolic syndrome or an estimated 10-year CVD risk of 7.5% or greater | G0446, Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes | Z01.31 Z13.220 Z13.6 Z71.3 |
9. Screening and counseling for domestic violence | All women | N/A | Covered as part of the Healthy You! preventive wellness visit | N/A | N/A | N/A |
10. Intimate Partner Violence: Screening USPSTF Recommendation: Recommends that clinicians screen for intimate partner violence (IPV) in women of reproductive age and provide or refer women who screen positive to ongoing support services | Women of reproductive age | N/A | Covered as part of the Healthy You! preventive wellness visit, prenatal visits, and postpartum check-up | N/A | N/A | N/A |
11. Intimate Partner Violence: Ongoing Support Services USPSTF Recommendation: Recommends that clinicians provide or refer women of reproductive age who screen positive for intimate partner violence (IPV) to ongoing support services | Women of reproductive age | 2 hours per calendar year | Two hours of counseling by a Licensed Clinical Social Worker (LCSW) about options and safety will be covered for women of reproductive age who screen positive for IPV. | Women with a positive screening for IPV using a valid, reliable screening tool | 99401 99402 99403 99404 | Z69.11, Encounter for mental health services for victim of spousal or partner abuse |
12. Skin Cancer Behavioral Counseling USPSTF Recommendation: Recommends counseling young adults, adolescents, children, and parents of young children about minimizing exposure to ultraviolet (UV) radiation for persons aged 6 months to 24 years with fair skin types to reduce their risk of skin cancer. | Fair skin children, adolescents, and young adults ages 6 months to 24 years | N/A | Covered as part of the Healthy You! preventive wellness visit | N/A | N/A | N/A |
13. Anticipatory Guidance AAP Recommendation: The anticipatory guidance component of every Bright Futures visit gives the health care professional, parents, and the child or adolescent a chance to ask questions and discuss issues of concern. This guidance is organized around 5 priority areas: Bicycle Helmets Children, Adolescents, and Media Cardiometabolic Risk of Obesity Tobacco Smoke Exposure and Tobacco Use Cessation Weight Maintenance and Weight Loss | 0 - 18 years | N/A | Covered as part of the Healthy You! preventive wellness visit | N/A | N/A | N/A |
14. Perinatal Depression: Preventive Interventions USPSTF Recommendation: Recommends that clinicians provide or refer pregnant and postpartum persons who are at increased risk of perinatal depression to counseling interventions. | All pregnant women and women less than one year postpartum | 4 hours of counseling interventions per pregnancy if determined to be at increased risk of perinatal depression Obstetrician– gynecologists and other obstetric care providers should screen patients at least once during the perinatal period for depression and anxiety symptoms using a standardized, validated tool | Four hours of counseling in the individual and/or group setting by a Psychologist will be covered for pregnant and postpartum persons who do not have a current diagnosis of depression but are at increased risk of developing depression. Screening for depression in pregnant and postpartum persons during the perinatal period is included within the global obstetrical service. | A personal or family history of depression History of physical or sexual abuse Having an unplanned or unwanted pregnancy Current stressful life events Pregestational or gestational diabetes Complications during pregnancy (eg, preterm delivery or pregnancy loss) Social factors such as: Low socioeconomic status Lack of social or financial support Adolescent parenthood perinatal depression. | 99401 99402 99403 99404 99411 99412 | R45.89 |
15. Behavioral Counseling Interventions for Healthy Weight and Weight Gain in PregnancyUSPSTF Recommendation: Recommends that clinicians offer pregnant persons effective behavioral counseling interventions aimed at promoting healthy weight gain and preventing excess gestational weight gain in pregnancy. | All pregnant women | 3 hours per pregnancy | Three hours of behavioral counseling (1 hour per trimester) with a Primary Care Network Provider in a routine prenatal care setting will be covered for all pregnant women per pregnancy. | N/A | G0447 | O26.00 - O26.03, O99.210 - |
G. | Contraception Counseling and Coverage | ||||||
|---|---|---|---|---|---|---|---|
Service | Age/Sex | Interval/Limits | Policy | Risk Factors | Procedure Code(s) | ICD-9 Diagnosis Code(s) | ICD-10 Diagnosis Code(s) |
1. Patient education and counseling of contraceptive methods | All women with reproductive capacity | N/A | Covered as part of the Healthy You! preventive wellness benefits | N/A | N/A | N/A | N/A |
2. Prescription Drug Contraception | All women with reproductive capacity | As prescribed | Prescription will be required at the pharmacy to obtain contraception. | N/A | N/A | N/A | N/A |
3. Other Food and Drug Administration (FDA) approved contraceptive methods | All women with reproductive capacity | FDA-approved birth control as prescribed/ordered by the healthcare provider *If contraceptive method is changed prior to the interval specified, the new method will be covered under medical benefits. | Must be prescribed/ ordered by healthcare provider Over-the-counter items without a prescription arenot covered under this policy. | N/A | 96372 J1050 J7294 J7295 J7304 11981 11982 11983 A4268 (3 boxes per month) A4269 (1 box per month) J7306* (1 implant every 5 years) J7307* (1 implant every 3 years) | V25.02 V25.49 V25.5 | Z30.013 - Z30.014, Z30.015 - Z30.017 Z30.018 - Z30.019 Z30.42, Z30.44 - Z30.46, Z30.49 |
4. Intrauterine Devices (IUDs), Insertion, and Removal | All women with reproductive capacity | 1 device and insertion at an interval of every 5 years 1 device removal at an interval of every 5 years *If contraceptive method ischanged prior to the intervalspecified, the new methodwill be covered under medicalbenefits. | N/A | N/A | 58300 58301 J7300* J7301* J7298* S4989 J7296 J7297 | V25.11 V25.12 V25.13 | Z30.430 Z30.432 Z30.433 |
5. Inpatient tubal ligation with c-section delivery | Postpartum women post C-section delivery | 1 per lifetime | N/A | N/A | 58565 58600 58605 58611 58670 58671 00851 | V25.2 | Z30.2 |
6. Inpatient tubal ligation post vaginal delivery | Postpartum women post vaginal delivery | 1 per lifetime | N/A | N/A | 58565 58600 58605 58615 58670 58671 00851 | V25.2 | Z30.2 |
7. Outpatient tubal ligation | All women with reproductive capacity | 1 per lifetime | N/A | N/A | 58565 58600 58605 58615 58670 58671 00851 | V25.2 | Z30.2 |
Federal Employee Program (FEP)
State Health Plan (State and School Employees)
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
12/01/2010: Policy added.
08/01/2012: Policy revised to add coverage and coding guidelines for the following women's preventive health services: breast feeding equipment, gestational diabetes screening, HIV screening and counseling, human papillomavirus (HPV) DNA testing, screening and counseling for domestic violence, and contraception coverage and counseling. Note: This policy revision will become effective for underwritten groups on January 1, 2013. For self-funded groups, coverage will become effective on the group's first renewal date on or after 08/01/2012. Please review the patient's benefits and eligibility prior to rendering services.
06/01/2013: Added new section for Other Immunization Services and added coverage guidelines for Human Papilloma virus (HPV) vaccine (GARDASIL) in males. Added ICD-9 code V28.89 as a diagnosis code for gestational diabetes screening. Added HCPCS code J1050 and ICD-9 code V25.5 to the Other Food and Drug Administration (FDA) approved contraceptive methods section.
09/10/2013: Added CPT codes 58565, 58670, and 58671 to the Contraception Counseling and Coverage section.
04/25/2014: Added CPT code 11981 and HCPCS code J7301 to the Contraception Counseling and Coverage section. Removed deleted HCPCS code J1055 for the section.
01/01/2015: Added coverage guidelines and risk factors for the following:
Low-Dose Aspirin Use for the Prevention of Morbidity and Mortality From Preeclampsia
Dental Caries Prevention in Children Age 5 Years and Younger
Hepatitis B Virus Infection Screening: Non-Pregnant Adolescents and Adults
Hepatitis C Virus Infection Screening: Adults
Lung Cancer Screening
Breast Cancer Preventive Medication (“Risk-Reducing Medications for Primary Breast Cancer: Tamoxifen and Raloxifene” medical policy)
Falls Prevention in Older Adults: Exercise or Physical Therapy
Falls Prevention in Older Adults: Vitamin D
Updated guidelines for BRCA Risk Assessment and Genetic Counseling/Testing. Added BRCA testing procedure codes 81211, 81212, 81213, 81214, 81215, 81216, and 81217 and ICD-9 diagnosis codes V84.01, Genetic susceptibility to malignant neoplasm of breast and V84.02, Genetic susceptibility to malignant neoplasm of ovary.
Added procedure codes 97001, 97110, 97112, and 97116 and ICD-9 diagnosis code V15.88 for reporting Falls Prevention in Older Adults: Exercise or Physical Therapy.
Added procedure code 99188 and ICD-9 diagnosis code V07.31 for reporting Dental Caries Prevention in Children Age 5 Years and Younger.
Added procedure code 87340 and ICD-9 diagnosis code V01.89 for reporting Hepatitis B Virus Infection Screening.
Added procedure code 86803 and ICD-9 diagnosis code V01.89 for reporting Hepatitis C Virus Infection Screening.
Added procedure code S8032 and ICD-9 diagnosis code V76.0 for reporting Lung Cancer Screening.
Added guidelines for IUD device removal once every 5 years. Added IUD removal procedure code 58301.
Added the following services as covered under the Healthy You! benefit: Alcohol and Drug Use Assessment; Osteoporosis Screening: Women; Skin Cancer Behavioral Counseling; Tobacco Use Counseling: Pregnant Women; Tobacco Use Interventions: Children and Adolescents; Tobacco Use Counseling and Interventions: Non-Pregnant Adults; Healthy Diet and Physical Activity Counseling to Prevent Cardiovascular Disease. Decreased the age range for Alcohol misuse counseling- Pregnancy, Adults from 21 to 18.
04/27/2015: Added procedure codes 87624 and 87625 for reporting Human papillomavirus (HPV) DNA testing. Removed deleted procedure codes 87620, 87621, and 87622. Added procedure code 11983 to the Contraception Counseling and Coverage section. Added procedure code 90651 for reporting GARDASIL 9 vaccine administration in males.
06/15/2015: Removed invalid ICD-9 diagnosis code V28.8 for Bacteriuria Screening. Added ICD-9 diagnosis V28.5 for reporting Rh (D) Incompatibility.
09/01/2015: Code Reference section updated for ICD-10. BRCA Risk Assessment and Genetic Counseling/Testing guidelines updated to state that BRCA testing is covered for females, age 18 and over, who have not been diagnosed with breast or ovarian cancer or who have a history of non-BRCA related cancer and whose family history is associated with an increased risk for deleterious mutations in BRCA1 or BRCA2 genes.
09/30/2015: Policy revised to add coverage guidelines for electric breast pumps and related supplies effective 10/01/2015. Added CPT code 11982 for removal of non-biodegradable drug delivery implant. Added that J7306 is allowed once every 5 years, and J7307 is allowed once every 3 years. Added coverage of A4268 (female condoms - 3 boxes per month) and A4269 (spermicide - 1 box per month). Policy also updated to add statement regarding coverage when changing contraceptive methods.
10/29/2015: Policy section updated to make the following corrections: For screening for anemia during pregnancy, Z3491 - Z38.93 changed to Z34.91 - Z34.93; for chlamydia screening during pregnancy, V34.03 changed to Z34.03; for syphilis screening for women 21 years and older, Z27.8 changed to Z57.8.
01/01/2016: Policy revised to add procedure codes 99211, 36415, 36416, 82247, 82248, and 88720 and ICD-10 diagnosis code Z00.110 to report an office visit for newborns 2-5 days after birth for health examination and bilirubin check. Changed the once per lifetime general osteoporosis screening for women from age 50 to 65. Removed HPV testing for females and HPV vaccines for males as these services have been added under the Healthy You! benefit for the ages and intervals specified in the Healthy You! Wellness Procedures coding guidelines effective 01/01/2016. Added the following new 2016 HCPCS and CPT codes: G0297, J7298, 80081, and 81162. Noted that HCPCS code J7302 was deleted on 12/31/2015.
06/06/2016: Policy number L.2.01.409 added.
07/01/2016: Policy revised regarding coverage for newborns: "Newborn Office Visit" changed to "Newborn Outpatient Visit." Policy statement revised to state that one outpatient visit will be covered for all newborns less than 8 days old for health examination and bilirubin check.
09/30/2016: Policy section revised to add the following new ICD-10 diagnosis codes: Z33.3, Z29.13, Z29.3, Z30.015 - Z30.017, and Z30.44 - Z30.46. Added CPT code 87389 for HIV screening and ICD-10 diagnosis code Z30.432 for IUD removal, effective 10/01/2016.
12/30/2016: Policy section updated to add procedure code G0499 for reporting Hepatitis B Virus Infection Screening and to add new 2017 procedure codes 76706 and 97163. Removed deleted HCPCS code J7302.
06/26/2017: Policy section updated to add new HCPCS code Q9984, effective 07/01/2017.
09/29/2017: Policy section updated to add new ICD-10 diagnosis codes Z36.2, Z36.5, Z36.89, Z36.9, Z91.841, Z91.842, Z91.843, and Z91.849, effective 10/01/2017. Removed deleted procedure code S8032.
12/22/2017: Policy section updated to add new 2018 HCPCS code J7296.
05/29/2018: Link in Sources section updated.
11/16/2018: Added coverage guidelines for the following: Prenatal Visit with Pediatrician, Latent Tuberculosis Screening for Adults, Oral Health Risk Assessment, Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer, Colorectal Cancer Screening: Stool DNA Testing (Cologuard), Colorectal Cancer Screening: Fecal Occult Blood Test (FOBT), and Anticipatory Guidance. Updated guidelines for chlamydia screening, gonorrhea screening, HIV screening, gestational diabetes mellitus (GDM) screening, hearing screening, obesity counseling for adults 19 and older, sexually transmitted infection counseling, and skin cancer behavioral counseling. For the hearing screening, the age range changed from "3-10 years" to "3-21 years." For latent tuberculosis screening for adults, added CPT codes 86480, 86481, and ICD-10 diagnosis codes Z11.1 and Z20.1. For fecal DNA testing, added CPT code 81528 and ICD-10 diagnosis codes Z12.10, Z12.11, Z12.12, and Z12.13. Removed deleted CPT code 97001 and ICD-10 diagnosis codes Z36. Sources updated.
12/19/2018: Added coverage guidelines for Urinary Incontinence Screening in women. Policy section updated to add new procedure codes 81163, 81164, 81165, 81166, and 81167, effective 01/01/2019.
01/18/2019: Added coverage guidelines for Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: Preventive Medication.
02/13/2019: Added coverage guidelines for Screening for Diabetes Mellitus after Pregnancy.
02/26/2019: Policy section for BRCA Risk Assessment and Genetic Counseling/Testing updated to add ICD-10 diagnosis codes Z80.41, Z80.49, and Z80.8.
06/03/2019: Policy language updated to change "alcohol misuse" to "unhealthy alcohol use" throughout. Age for beginning alcohol and drug use assessment changed from 11 to 9 years of age.
09/24/2019: Code Reference section updated to add new ICD-10 diagnosis code Z11.7, effective 10/01/2019. Removed deleted HCPCS code Q9984.
10/01/2019: Policy revised to add coverage and coding guidelines for behavioral counseling for obesity for adults, children, and adolescents. Note: This policy revision will become effective for Fully Insured Groups on January 1, 2020. For Self-Funded groups, coverage will become effective on the Group's first renewal date on or after 10/01/2019. Please review the patient's benefits and eligibility prior to rendering services.
11/01/2019: Policy revised to add coverage and coding guidelines for intimate partner violence screening and counseling. Note: This policy revision will become effective for Fully Insured Groups on January 1, 2020. For Self-Funded groups, coverage will become effective on the Group's first renewal date on or after 11/01/2019. Please review the patient's benefits and eligibility prior to rendering services.
12/03/2019: Added CPT codes 99381 and 99391 to the Newborn Outpatient Visit section effective 01/01/2019.
12/20/2019: Policy updated to add new HCPCS code K1005 effective 01/01/2020.
01/01/2020: Policy updated to add HCPCS code J7297. Removed deleted CPT codes 81211, 81213, and 81214.
03/01/2020: Policy revised to add coverage and coding guidelines for preventive interventions for perinatal depression. Note: This policy revision will become effective for Fully Insured Groups on January 1, 2021. For Self-Funded groups, coverage will become effective on the Group's first renewal date on or after 03/01/2020. Please review the patient's benefits and eligibility prior to rendering services.
07/01/2020: Policy revised to add coverage guidelines for Prevention of Human Immunodeficiency Virus (HIV) Infection: Preexposure Prophylaxis.
09/01/2020: Policy revised to add coverage and coding guidelines for Risk Assessment, Genetic Counseling, and Genetic Testing for BRCA-Related Cancer. Note: This policy revision will become effective for Fully Insured Groups on January 1, 2021. For Self-Funded groups, coverage will become effective on the Group's first renewal date on or after September 1, 2020. Please review the patient's benefits and eligibility prior to rendering services.
10/01/2020: Policy revised to add coverage of aromatase inhibitor to reduce breast cancer risk.
12/16/2020: Code Reference section updated to add new CPT code 71271, effective 01/01/2021.
07/01/2021: Policy revised to add coverage guidelines for Unhealthy Drug Use: Screening.
08/04/2021: Policy revised regarding coverage for Hepatitis C Infection Screening.
09/01/2021: Policy revised to update the coverage guidelines for Behavioral Counseling Interventions to Prevent Sexually Transmitted Infections.
09/17/2021: Policy revised to add coverage for baseline testing and monitoring of adolescents and adults prescribed Pre-Exposure Prophylaxis for HIV.
10/01/2021: Code Reference section updated to add new HCPCS codes J7294 and J7295, effective 10/01/2021.
10/28/2021: Policy revised to update guidelines for tobacco cessation interventions, specifically to state that FDA-approved pharmacotherapy for cessation is covered for adults as part of the Be Tobacco-free program and to add that counseling is available for adolescents 16 years and older with parental consent as part of the Be Tobacco-free program.
12/01/2021: Policy revised to update the coverage guidelines for Behavioral Health Counseling Interventions to Promote a Healthy Diet and Physical Activity for Cardiovascular Disease Prevention in Adults with Cardiovascular Risk Factors.
12/09/2021: Policy updated to state that effective 01/01/2022, colorectal cancer screening using Fecal DNA Testing (Cologuard) and high-sensitivity FOBT will be covered beginning at age 45.
04/01/2022: Policy revised to update the coverage guidelines for lung cancer screening to lower the age to begin screening from 55 to 50 and to decrease the pack-years from 30 to 20. Removed deleted HCPCS code G0297.
05/23/2022: Policy revised to update the coverage guidelines for the Prevention of HIV Infection: Preexposure Prophylaxis policy statement to add the term "generic" and to remove "Truvada®" brand name.
06/01/2022: Policy revised to add coverage guidelines for the following: 1) Colorectal Cancer Screening: Follow-Up Colonoscopy, and 2) Behavioral Counseling Interventions for Healthy Weight and Weight Gain in Pregnancy.
10/17/2022: Policy section revised to update the coverage guidelines for Syphilis Screening.
01/18/2023: Policy reviewed; no changes.
05/01/2023: Policy revised to update the risk factors for Syphilis Screening.
08/01/2023: Policy revised to update the coverage guidelines for Depression Screening.
09/29/2023: Policy updated to add new ICD-10 diagnosis code Z29.81, effective 10/01/2023.
11/01/2023: Policy revised to add coverage guidelines for Anxiety in Children and Adolescents: Screening.
11/15/2023: Policy revised to add coverage and coding guidelines for Lactation/Breastfeeding support and counseling.
12/21/2023: Policy updated to add new 2024 HCPCS codes A4287, G0011, G0012, and G0013, effective 01/01/2024.
02/15/2024: Policy reviewed. Policy section updated to remove deleted HCPCS code J7303.
10/01/2024: Code Reference section updated to add new ICD-10 diagnosis codes Z68.55 and Z68.56.
03/13/2025: Policy reviewed; no changes.
10/01/2025: Code Reference section updated to add new HCPCS code A4288. Removed deleted HCPCS code K1005.
01/01/2026: Policy criteria updated to add Cologuard Plus. Added CPT Code 0464U.
U.S. Preventive Services Task Force Recommendations https://www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations .
Federal Register / Vol. 75, No. 137 / Monday, July 19, 2010 / Rules and Regulations
USPSTF Preventive Services Database -
HRSA Recommended Preventive Services
https://mchb.hrsa.gov/maternal-child-health-topics/recommended-preventive-services.html
See table in "Policy" section above.
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