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Preventive Care Services (P)

PREVENTIVE CARE SERVICES

The following is a list of preventive services (HCP rider) along with the diagnoses and procedure codes that your health plan has determined to meet and in some situations exceed the requirements and recommendations issued by the Affordable Care Act. Your Health Plan will process these claims in a manner that is intended to comply with Section 1557 of the Affordable Care Act. Preventive services are still subject to medical management criteria.

Some or all of the contraceptives methods or prescription drugs listed may not be covered under your health plan because of the employer’s religious beliefs. To find out if contraceptives methods and prescriptions drugs are excluded, please contact Customer Service for additional information. 

**Services are still subject to Medical Management Criteria. **

 

 

*Blue represents coding updates.

DESCRIPTION

CODING

NOTES

ABDOMINAL AORTIC ANEURYSM, SCREENING

  • Males only (with any history of smoking)

  • Ages 65-75 years

  • One in a lifetime

76706 with diagnosis Z13.6, Z72.0, Z87.891, or F17.200-F17.219, F17.290-F17.299

 

ALCOHOL MISUSE SCREENING AND BEHAVIORAL COUNSELING INTERVENTIONS

  • One each calendar year (as needed)

G0442 and G0443 with diagnosis Z13.89, or F10.10, F10.11, F10.120, F10.129, F10.130, F10.139, F10.90, F10.91, Z13.39

 

 

ASPIRIN USE TO PREVENT PREECLAMPSIA AND RELATED MORBIDITY AND MORTALITY: PREVENTIVE MEDICATION

 

  • Females age 10 years and older
 To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy  

ASYMPTOMATIC BACTERIURIA IN PREGNANT WOMEN, SCREENING

87081, 87084, 87086, or 87088 with a routine prenatal or high risk prenatal diagnosis code

See end of document for a list of routine and high-risk prenatal diagnosis codes

BREAST AND OVARIAN CANCER SUSCEPTIBILITY, GENETIC RISK ASSESSMENT AND BRCA MUTATION TESTING

  • Females only
  • One session in a lifetime

Counseling:

96041 or 99401-99404 with diagnosis Z15.01, Z15.02, Z31.5, Z71.83, Z80.3, Z80.41, Z85.3 or Z85.43

Genetic Testing:

81163, 81164, 81165, 81166, 81167, 81212, 81215, 81216, and 81217 with diagnosis Z15.01, Z15.02, Z31.5, Z71.83, Z80.3, Z80.41, Z85.3 or Z85.43 OR 81162 and 81212 with diagnosis Z15.01, Z15.02, Z31.5, Z71.83, Z80.3, Z80.41, Z85.3 or Z85.43

12/31/24- Removed 96040

1/1/25- Added 96041

Combined with chemo prevention of breast cancer

 

 

 

 

 

 

BREAST CANCER PREVENTION MEDICATION

  • Pharmacy only
  • Females only age 35 and older

To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy.

 

BREAST CANCER SCREENING

  • One baseline screening mammogram for females ages 35-39 years
  • One screening mammogram annually for females age 40 and over

77063, 77065, 77066, or 77067 with routine diagnosis

Effective 1/1/26, the following services will process under the Preventive Benefit when filed with a Breast Cancer Screening Evaluation Diagnosis (BCSED) code AND when filed within 90 days of a screening mammogram (77067):

  • Mammography/Tomosynthesis- 77061, 77062, 77065, 77066
  • Breast Ultrasound- 76641, 76642
  • Biopsy/Pathology: 10021, 10004, 10005, 10006, 10007, 10008, 10009, 10010, 10011, 10012, 19000, 19001, 19100, 19101, 19120, 19125, 19126, 19081, 19082, 19083, 19084, 19085, 19086, 10035, 10036, 19281, 19282, 19283, 19284, 19285, 19286, 19287, 19288, A4648, 88172, 88173, 88177, 88305, 88307, 88331, 88332, 88342, 88361, 88374, 88321
  • Anesthesia- 00400, 99156, 99157
  • Breast MRI- 77046, 77047, 77048, 77049

 

**Note: Breast MRI services are not subject to 90-day screening window requirement

Breast Cancer Screening Evaluation Diagnosis (BCSED) Codes:

Z12.31, Z12.39, D24.1, D24.2, D24.9 R92.0, R92.1, R92.2, R92.3, R92.30, R92.31, R92.311, R92.312, R92.313, R92.32, R92.321, R92.322, R92.323, R92.33, R92.331, R92.332, R92.33, R92.34, R92.341, R92.342, R92.343, R92.8, N60.01, N60.02, N60.09, N60.11, N60.12, N60.19, N60.21, N60.22, N60.29, N60.31, N60.32, N60.39, N60.41, N60.42, N60.49, N60.81, N60.82, N60.89, N60.91, N60.92, N60.99, N63.0, N63.10, N63.11, N63.12, N63.13, N63.14, N63.15, N63.20, N63.21, N63.22, N63.23, N63.24, N63.25, N63.31, N63.32, N63.4, N63.41, N63.42, N64.89 

 

 

 

 

         

BREASTFEEDING, BEHAVIORAL INTERVENTIONS TO PROMOTE

  • Females only
  • Twice per calendar year

99401 must have modifier TH and diagnosis O09.00-O09.93, O09.A0-O09.A3, O36.80X0-O36.80X9, Z33.1, Z33.3, Z34.00-Z34.93 or Z39.1

 

CERVICAL CANCER, SCREENING (PAP SMEAR)

  • One each calendar year
  • No age limitations

88141, 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88155, 88164, 88165, 88166, 88167, 88174, 88175, G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001, or Q0091 with routine diagnosis

 

CHEMOPREVENTION OF BREAST CANCER

  • Females only
  • One in a lifetime

99401 or 99402 with diagnosis code Z80.3 or Z15.01

Combined with BRCA benefit 

CHLAMYDIA INFECTION, SCREENING

  • Females age 15-21
  • One each calendar year

 

  • Females age 22 years and older
  • One each calendar year

 

87110, 87270, 87320, 87490, 87491, 87492, or 87810 with routine diagnosis except Z11.3 (see STI Screening) OR 86631, 86632 with diagnosis Z11.8

 

 

 

87110, 87270, 87320, 87490, 87491, 87492, or 87810 with routine diagnosis OR 86631, 86632 with diagnosis Z11.8

 

 

ROUTINE CHOLESTEROL (LIPID DISORDERS IN ADULTS), SCREENING

  • Men age 35 years and older (20-35 at risk for CAD)
  • Women age 45 years and older (20-45 at risk for CAD)
  • One every 5 calendar years

80061, 82465, 83718, 83721, 84478 with routine diagnosis

 

 

COLORECTAL CANCER, SCREENING

Pre-Screening Consultation

  • Once every 10 calendar years
  • Ages 45-75 years

 

 

 

Colonoscopy

  • Once every 10 calendar years
  • Ages 45-75 years

Includes outpatient facility services, physician services, and anesthesia.

 

Bowel Prep Medications

  • Ages 45-75 years

 

 

 

 

 

Sigmoidoscopy

  • Ages 45-75 years
  • Once every 3 calendar years

 

 

Barium Enema 

  • Ages 45-75 years
  • Once every 5 calendar years

 

 

 

Fecal Occult Blood Testing (FOBT)

  • Ages 45-75 years
  • One each calendar year

 

 

FIT-DNA (e.g., Cologuard, Cologuard Plus)

  • Ages 45-75 years
  • Once every 3 calendar years

 

 

 

CT Colonography (Visual Colonoscopy)

  • Ages 45-75 years
  • Once every 5 calendar years

Pre-Screening Consultation

99386 or 99387 with diagnosis code Z12.11
Or
99396 or 99397 with diagnosis code Z12.11
Or
S0285 with diagnosis Z12.11

 

Colonoscopy (with routine diagnosis)

G0121, G0105, 44388, 44389, 44390, 44391, 44392, 44394, 44401, 44402, 44403, 44404, 44405, 44406, 44407, 45378, 45379, 45380, 45381, 45382, 45384, 45385, 45386, 45388, 45389, 45390, 45391, 45392

8/1/25 Added 44403, 45390

Anesthesia (with routine diagnosis)

00811, 00812, 00813, 99151, 99152, 99153, 99155, 99156, 99157, G0500

 

Bowel Prep Medications

  • PEG-3350/NaCl/Na Bicarbon (NDC 10572030201)
  • PEG-3350/NaCl/Na Bicarbon (NDC 10572040001)
  • Gavilyte-N/Flavor Pack (NDC 43386005019)
  • Trilyte (NDC 51525683104)
  • PEG-3350/NaCl/Na Bicarbon (NDC 64380076921)

(GPIs: 46992004302120, 46992004302130, 46992004302140 (MSC=Y) only)

 

 

 

Sigmoidoscopy (with routine diagnosis)

G0104 or 45330, 45331, 45332, 45333, 45334, 45335, 45338, 45346, 45340, 45341, 45342, 45347

 

 

 

 

Barium Enema

74280 with routine diagnosis

12/31/24 Removed G0106, G0120, G0122

 

 

Fecal Occult Blood Testing (FOBT)

G0107, G0328, G0394, 82270, 82272, or 82274 with routine diagnosis

 

 

FIT-DNA (Cologuard™)

81528, 0464U with routine diagnosis

12/18/24 Added 0464U

 

CT Colonography (Visual Colonoscopy)

74263 with routine diagnosis
  • Follow-up colonoscopy after a positive stool-based test considered under the preventive benefit when billed in accordance with preventive guidelines. 
  • Exams of biopsy(-ies) specimens (including polyps(s)) collected during a colonoscopy or sigmoidoscopy completed on the same date of service will also process without cost-sharing.

CONGENITAL HYPOTHYROIDISM, SCREENING

  • Newborns-Ages 2-4 days

84436, 84437, 84439, or 84443 with diagnosis Z13.29

 

DENTAL CARIES IN CHILDREN FROM BIRTH THROUGH AGE 5 YEARS, PREVENTION OF

  • Birth–5 years

  • Male and Females

  • Maximum 4 per calendar year

CPT 99188 with Z29.3

 

 

 

DENTAL CARIES IN PRESCHOOL CHILDREN, PREVENTION

Included in preventive office visit

Per AAP’s Bright Futures Guidelines, this recommendation refers to the anticipatory guidance for oral health as an integral part of comprehensive patient counseling in the primary care setting.

DEPRESSION, ANXIETY, AND SUICIDE RISK SCREENING

  • Ages 8 years and older
  • Three each calendar year

G0444, 96127 with diagnosis Z13.31 or Z13.32 1/1/2023 add Z13.39

 

 

DEVELOPMENTAL SCREENING

  • Ages birth-30 months
  • Five services during age range

G0451 or 96110 with a routine diagnosis code

 

DEVELOPMENTAL SURVEILLANCE FOR CHILDREN

Included as part of an office visit

 

DEVELOPMENTAL/BEHAVIORAL ASSESSMENT – ALCOHOL AND DRUG

  • Ages 11-21 years
  • One each calendar year with any diagnosis

99408, G2011, G0396, G0442, G0443, or H0001

No specific diagnosis required

 

 

DYSLIPIDEMIA SCREENING

  • Ages 2-10 years: Once every 2 calendar years
  • Ages 11-17 years: One each calendar year
  • Ages 18-21 years: Once during age range

80061 with diagnosis Z13.220

 

DIET COUNSELING, BEHAVIORAL COUNSELING IN PRIMARY CARE TO PROMOTE A HEALTHY DIET 

  • Three hours each calendar year
  • Ages 18 and older

97802-97804, G0270, G0271, G0446, G0447 with diagnosis Z71.3, A18.84, E08.00-E13.9, E66.01-E66.1, E66.811, E66.812, E66.813, E66.89, E66.9, E78.00, E78.01, E78.1, E78.2, E78.3, E78.41, E78.49, E78.5, E78.6, E88.810, E88.811, E88.818, E88.819, R03.0, I10-I22.9, I16.0, I16.1, I16.9, I20.2, I20.81, I20.89, I21.9, I21.A1, I21.A9, I21.B, I24.0-I25.9, I42.0-I43, I50.1-I50.9, I51.5-I51.7, I51.9, I52, N26.2, O24.011-O24.33, O24.811-O24.93, O99.210-O99.215, or Z68.30-Z68.45

10/1/24 Removed E66.8. Added E66.811, E66.812, E66.813, E66.89

10/1/25 Removed E78.01. Added E11A, E78.010, E78.011, E78.019

 

GONORRHEA, SCREENING

  • Female only ages 22 years and older

(Ages 11-21 included in STI screening)

  • Two each calendar year

87590, 87591, or 87850 with diagnosis Z11.3

 

 

GONORRHEA, PROPHYLACTIC MEDICATION, NEWBORN

No code available-usually administered as an ancillary charge while inpatient at time of delivery

 

HEALTHY WEIGHT AND WEIGHT GAIN IN PREGNANCY, COUNSELING

  • Ages 10 and older
  • Three hours each calendar year
 99401-99404 with a routine prenatal diagnosis code, high risk prenatal diagnosis code   

HEMATOCRIT OR HEMOGLOBIN

  • Ages 4 months-10 years, no more than 3 tests.
  • Ages 11-21 years-one each calendar year

85013, 85014 or 85018 with diagnosis Z13.0

 

 

 

HEPATITIS B VIRUS INFECTION IN PREGNANCY, SCREENING FOR

  • Females (pregnant)
  • One each calendar year

87340 with diagnosis O09.00-O09.93, O36.80X0-O36.80X9, Z33.1, Z33.3, or Z34.00-Z34.93

 

 

 

 

HEPATITIS B VIRUS INFECTION IN NONPREGNANT ADOLESCENTS AND ADULTS, SCREENING FOR

  • Ages newborn and older
  • One each CPT code per calendar year

G0499, 86704, 86705, 86706, 87340 or 87341 with diagnosis Z21, Z51.11, Z51.12, Z57.8, Z63.6, Z63.79, Z65.1, Z65.2, Z77.21, Z86.19, Z86.2, Z92.25, Z92.29, Z99.2, B17.10, B17.11, B18.2, B19.20 or B19.21

 

 

HEPATITIS C VIRUS (HCV) INFECTION, SCREENING

  • Once per lifetime screening for males and females
  • Once per year screening for males and females at high risk for infection
  • 86803, 86804, G0472 – once per lifetime for males and females
  • 86803, 86804, G0472 – once per year for males and females at high risk for infection with diagnosis codes Z92.29, Z77.21, Z99.2, Z65.1, Z65.2, Z57.8, Z11.3, Z11.9, Z72.89, Z72.511, Z72.52, Z72.53, Z11.59, Z20.5, Z20.828, Z77.21

 

 

HIGH BLOOD PRESSURE, SCREENING

  • One each calendar year as needed.
  • Ages 18 years and older

Included in office visit

 

 

 

 

 

 

 

 

HIGH BLOOD PRESSURE SCREENING (OUTSIDE OF THE CLINICAL SETTING)

Ambulatory Blood Pressure Monitoring:

  • One per lifetime to confirm the diagnosis of hypertension
  • Ages 18 years and older

 

Self-Measured Blood Pressure Monitoring:

  • One per lifetime to confirm the diagnosis of hypertension
  • Ages 18 years and older

Ambulatory Blood Pressure Monitoring:

93784 OR 93786, 93788, 93790 with diagnosis R03.0

 

Self-Measured Blood Pressure Monitoring:

99473-99474 with diagnosis R03.0

 

 

 

 NOTE: Do not report ambulatory BP monitoring in the same calendar month as self-measure BP.

HIGH BODY MASS INDEX IN CHILDREN AND ADOLESCENTS, INTERVENTIONS

Effective 7/1/2025

  • Ages 6 to 17 years 
  • 26 services per year
 97802, 97803, 97804, G0270, G0271, G0447 with diagnosis E66.01, E66.09, E66.1, E66.2, E66.811, E66.812, E66.813, E66.89, E66.9, Z68.54, Z68.55, Z68.56  

HIV SCREENING

  • Ages 11 years and older
  • No frequency

 

86701, 87535, 87534, 87389, 87390, 86703, 87806, G0432, G0433, G0435, G0475 with diagnosis Z11.4

 

HUMAN PAPILLOMAVIRUS (HPV) 

  • Ages 30 years and older (Females only)
  • One every 3 calendar years

G0476, 87623, 87624, 87625, or 87626 with routine diagnosis

12/31/24- Removed 0500T

1/1/25- Added 87626 

 

IMMUNIZATIONS

Routine Immunizations – Standard PMD Contracts

 

Routine Immunizations-Coverage is based on CDC’s Advisory Committee in Immunization Practices (ACIP) recommendations regarding age, frequency, and dosage.

Refer to the CDC website to view the schedules:

https://www.cdc.gov/vaccines/ 

INPATIENT NEWBORN CARE

  • Newborns

Inpatient physician services only

99221-99223, 99231-99233, 99234-99236, 99238, 99239, 99460, 99462-99464, 99478-99480 with a routine diagnosis

 

IRON DEFICIENCY ANEMIA, PREVENTION

Pharmacy Benefit

 

IRON DEFICIENCY ANEMIA, SCREENING

  • Females (pregnant)
  • One each calendar year

85013, 85014, 85018, 85025, OR 85027 with diagnosis O09.00-O09.93, O36.80X0-O36.80X9, Z33.1, Z33.3, OR Z34.00-Z34.93

 

LEAD SCREENING

  • Ages 6 months – 6 years
  • 3 tests during age range

83655 with diagnosis Z13.88

 

LUNG CANCER, SCREENING WITH LOW-DOSE COMPUTED TOMOGRAPHY

  • 50-80 years old
  • Male and Females
  • One each calendar year

71271 with Z12.2 AND Z87.891, F17.210, F17.211, F17.213, F17.218 OR F17.219

 

MATERNAL DEPRESSION SCREENING

  • Ages birth-6 months
  • 4 services during age range

96161 with routine diagnosis

 

 

NEWBORN METABOLIC/HEMOGLOBIN SCREENING

  • Ages 0-2 months
  • One test during age range

S3620 with no specific diagnosis required

 

NEWBORN SCREENING PANEL

  • Ages birth-31 days

83498 or 83788 with Z13.21, Z13.228, Z13.29

83020 with Z13.0

82261 with Z13.21, Z13.228, Z13.29

83516 with Z13.228

82776 with Z13.228

86355 or 86359 with Z13.21, Z13.228, Z13.29

82760 with Z13.228

82759 with Z13.228

86359 with Z13.21, Z13.228, Z13.29

83789 with Z13.228

 

OBESITY IN ADULTS AND CHILDREN SCREENING

  • Ages 6 years and older
  • One per calendar year

99401, G0447 with diagnosis Z13.89, Z68.53, Z68.54, Z68.55, Z68.56

10/1/24 Added Z68.55, Z68.56

 

ORAL HEALTH

  • Ages 6 months-6 years
  • 3 services during age range

96160 with Z13.84

 

OSTEOPOROSIS IN POSTMENOPAUSAL WOMEN SCREENING

  • Ages 65 and older. 65 and younger if at risk
  • Females only
  • Once every 2 calendar years

77080 with diagnosis E05.00-E05.91, E10.10-E10.9, E23.6, E28.310- E28.39 E44.0-E46, E64.0, E89.40, E89.41, F10.20-F10.220, F10.229, F17.200-F17.299, K70.0-K70.40, K70.9, K73.0-K74.69, K75.4, K75.81, K76.0, K76.89, K76.9, K90.0-K90.49, K90.89, K90.9, K91.2, M05.00-M06.9, M08.00- M08.9A, M12.00-M12.09, M45.0-M45.9, M45.A0, M45.A1, M45.A2, M45.A3, M45.A4, M45.A5, M45.A6, M45.A7, M45.A8, M45.AB, M48.8X1-M48.8X9, Q78.0, Q96.0-Q96.9, Z13.820, Z71.41, Z72.0, Z82.62, Z86.39, Z87.310-Z87.312, Z87.81, Z90.721- Z90.79, or Z92.241

 

 

 

 

 

 

 

CONTRACEPTIVE METHODS

  • Women only
  • Generic only
 To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy.  

FLUORIDE (OVER–THE–COUNTER)

  • Ages 6 months – 16 years
 To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy.  

FOLIC ACID (OVER–THE–COUNTER)

  • Women only
 To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy.  

IRON SUPPLEMENTS (OVER–THE–COUNTER)

  • Ages 6 months to 12 months
 To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy.  

PHENYLKETONURIA SCREENING (PKU)

  • Ages 2-14 days
  • Two tests during age range

84030 with diagnosis Z13.228

 

 

 

 

PROSTATE SPECIFIC ANTIGEN (PSA)

  • Ages 40 years and over
  • Annually

G0103 or 84153 with routine diagnosis

 

 

RH (D) INCOMPATIBILITY, SCREENING

  • Two per calendar year
  • Females only

86901 with diagnosis O09.00-O09.93, O36.80X0-O36.80X9, Z33.1, Z33.3, or Z34.00-Z34.93

 

PREECLAMPSIA SCREENING

  • Females only beginning at age 10

Included in prenatal office visit

 

Prenatal Conference

  • with Pediatricians only

CPT codes 99202-99203 or 99211-99213 with diagnosis Z76.81

 

PREVENTION OF FALLS

  • Age 65 years and older

97110, 97112, 97116, G0151, or G0159 with diagnosis Z91.81, limited to 40 services each calendar year (= 10 hours of physical therapy)

OR

97150 with diagnosis Z91.81, limited to 10 services each calendar year

OR

S9131 with diagnosis Z91.81, limited to 10 services each calendar year

 

PREVENTION OF HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTION: PRE-EXPOSURE

To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy.


The following services for baseline/follow-up testing and monitoring are included per the CDC PrEP guidelines with diagnosis codes, Z11.3, Z11.4, Z20.2, Z20.6, Z20.828, Z20.89, Z20.9, Z29.81, Z51.81, Z72.51, Z72.52, Z72.53, Z72.89, Z77.21, OR Z79.899:

  • Kidney function testing (creatinine): 82565, 82575
  • Hepatitis B testing: G0499, 86704, 86705, 86706, 87340 or 87341
  • Hepatitis C testing: 86803, 86804, G0472
  • HIV: 86701, 87535, 87534, 87390, 86703, 87389, 87806, G0432, G0433, G0435 or G0475
  • STI Testing: 86592, 86780, 87590, 87591, 87850, 86631, 86632, 86701, 86703, 87081, 87110, 87205, 87210, 87270, 87320, 87490, 87491, 87590, 87591, 87810, 87850, 87563
  • Preventive Medicine Counseling: G0011, G0012, G0013, 99401, 99402
  • Pregnancy testing (when appropriate): 81025, 84702, 84703
  • E/M Office Visits (do not report with Z51.81, Z79.899)


Physician-administered pre-exposure prophylaxis- Apretude (cabotegravir) J0739 with NDC 49702-0264-23 (ages 12 and older) with Z11.3, Z11.4, Z20.2, Z20.6, Z20.828, Z20.89, Z20.9, Z29.81, Z51.81, Z72.51, Z72.52, Z72.53, Z72.89, Z77.21, Z79.899

 

 

1/1/24 Added G0011, G0012, G0013

1/1/25- Added Z20.828, Z20.89, Z20.9

  

PREVENTIVE HISTORY AND PHYSICAL EXAMINATIONS

  • 9 visits the first 2 years of life
  • Age 2 years -two per birth year
  • Ages 3-6 years -one each year (based on birth year)
  • Ages 7 years and older- one each calendar year

G0101, G0102, G0438, G0439, G0463, G0513, G0514, S0612, S0613, 99202 - 99215, 99241 - 99245, 99381 - 99387, 99391 - 99397

 

PSYCHOSOCIAL/BEHAVIORAL ASSESSMENT

  • Newborn – 21 years
  • 31 services during age range

96127 with routine diagnosis

HEARING, SENSORY SCREENING 

  • Ages 2 months-10 years – no more than eight tests
  • Ages 11-21 years – no more than three tests

92551, 92552, 92558, 92567, 92587, 92650, 92651 or V5008 with diagnosis Z00.121, Z00.129, Z01.10, Z01.118 or Z13.5

 

HEARING, NEWBORN SCREENING 

  • Newborn-31 days 
  • One in a lifetime

92558, 92587, 92650, 92651 with diagnosis Z00.110, Z00.111, Z00.121, Z00.129, Z01.10, Z01.118, Z13.5

 

 

SEXUALLY TRANSMITTED INFECTIONS, BEHAVIORAL COUNSELING INTERVENTIONS TO PREVENT

  • Ages 10 years and older once each calendar year

 

99401, 99402, G0445 with diagnosis Z71.89, Z72.51, Z72.52 OR Z72.53 OR 99403, 99404, G0445 with diagnosis Z71.7, Z71.89, Z72.51, Z72.52, OR Z72.53

 

 

 

SEXUALLY TRANSMITTED INFECTIONS (STI), SCREENING

  • Ages 11-21 years
  • No frequency

86631, 86632, 86701, 86703, 87081, 87110, 87205, 87210, 87270, 87320, 87490, 87491, 87563, 87590, 87591, 87810, or 87850 with diagnosis Z11.3

 

 

SICKLE CELL DISEASE SCREENING

  • Age 0-31 days
  • No frequency

83020 or 83021 with diagnosis Z13.0

 

SKIN CANCER, BEHAVIORAL COUNSELING TO PREVENT

  • Ages 6 months-24 years

Included in E&M and/or preventive office visits

 

STATIN USE FOR THE PRIMARY PREVENTION OF CARDIOVASCULAR DISEASE IN ADULTS

  • Ages 40-75 years
  • No history of cardiovascular disease (CVD)
  • One or more risk factors
  • Calculated 10-year CVD event risk of 10% or greater

 

To be considered under the Pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy

Generic Pravastatin and Lovastatin are included products

SYPHILIS INFECTION SCREENING

  • No frequency

86592 or 86780 with diagnosis Z11.3

 

 

SUDDEN CARDIAC ARREST AND SUDDEN CARDIAC DEATH SCREENING

  • Ages 11-21 years
 Included in E&M and/or preventive office visits  

TOBACCO USE AND TOBACCO-CAUSED DISEASE COUNSELING

  • 8 total per calendar year
  • Ages 6 years and older

Pregnant Females

  • 8 total per calendar year
  • Ages 10 years and older

99406, 99407 diagnosis F17.200-F17.299, or Z72.0

Pregnant Females

99406 or 99407 with diagnosis O99.330-O99.333

 

TOBACCO USE AND TOBACCO-CAUSED DISEASE, MEDICATION

  • Two 90 day supplies

 

To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled at the pharmacy.

All Food and Drug Administration (FDA)-approved tobacco cessation medications (including both prescription and over-the-counter medications) for a 90-day treatment regimen when prescribed by a health care provider without prior authorization.

TYPE 2 DIABETES MELLITUS IN ADULTS, SCREENING

  • Males Ages 19 years and older
  • Females Ages 10 years and older
  • Once every 3 years

82947 OR 83036 with diagnosis Z13.1, Z86.32

 

TUBERCULIN TEST

  • Ages 1 month-21 years
  • 6 tests during age range

86580 with diagnosis Z11.1

 

TUBERCULOSIS INFECTION, LATENT, IN ADULTS, SCREENING FOR

  • Adults at risk, ages 19 years and older

  • Once per year allowed if at risk or continued risk

86580, 86480, OR 86481 with diagnosis Z11.1, Z11.7

 

 

 

UNHEALTHY DRUG USE SCREENING (ADULTS)

  • Ages 18 years and older
  • Once each calendar year 
 G0396, G2011, H0001 or 99408  

URINARY INCONTINENCE, SCREENING

  • Females Ages 10 years and older

Included in E&M and/or Preventive office visits

 

VISUAL ACUITY SCREENING IN CHILDREN

  • Newborn – age 10 – limited to 8 tests in age range
  • Ages 11-21 years – limited to 4 tests during age range

99173, 99174, 99177 with diagnosis Z00.110, Z00.111, Z01.00, Z00.129, Z00.121, Z01.01 or Z13.5

 

 

WOMEN’S PREVENTIVE SCREENINGS

DESCRIPTION

CODING

NOTES

WELL WOMAN PREVENTIVE OFFICE VISITS

  • Females only beginning at age 10

 

CPT codes 99383-99387, 99459, G0438, or S0610 with diagnosis Z00.00 or Z00.01 – limited to 1 per calendar year

CPT codes 99383-99387, 99459, G0438, or S0610 with diagnosis Z01.411 or Z01.419 – limited to 1 per calendar year

CPT codes 99393-99397, 99459, G0439, 
S0612, or S0613 with diagnosis Z00.00, Z00.01, Z01.411, or Z01.419 – limited to 2 per calendar year  


1/1/24 Added 99459

NOTE: Pelvic Examination add-on code 99459 should process per preventive services benefits when submitted in conjunction with the Well Woman Preventive Office Visits. 

PERINATAL DEPRESSION PREVENTIVE INTERVENTIONS

  • Ages 10 and older
  • Females only
  • Three hours each calendar year
 99401-99404 with a routine prenatal diagnosis code, high risk prenatal diagnosis code OR Z39.2  

PRECONCEPTION

  • Females only beginning at age 10
  • One visit per calendar year

99383-99387, G0438, or S0610 with Z31.69 or Z31.7

 

PRENATAL CARE

  • Females only beginning at age 10

 

99202-99215 with routine prenatal diagnosis, limited to 3 visits each calendar year

99202-99215 with high risk prenatal diagnosis

59425 regardless of diagnosis, limited to 2 visits each calendar year

59426 regardless of diagnosis, limited to 1 visit each calendar year

Codes for prenatal visits should be filed separate from global maternity to ensure member coverage at 100% with no cost share.

See end of document for a list of routine and high-risk prenatal diagnosis codes.

SCREENING FOR DIABETES AFTER PREGNANCY

Effective 1/1/24

  • Females only beginning at age 10
  • Limit two per calendar year
 82947, 83036, 82951, or 82952 with Z86.32  

SCREENING FOR DIABETES DURING PREGNANCY

  • Females only beginning at age 10
  • Limit two per calendar year

 

82947, 83036, 82951, or 82952 with a routine prenatal or high risk prenatal diagnosis

 

See end of document for a list of routine and high-risk prenatal diagnosis codes.

HIV COUNSELING

  • Females only beginning at age 10
  • Annually

99401 or 99402 with diagnosis Z71.7

 

CONTRACEPTIVE METHODS AND COUNSELING

  • Female only beginning at age 10
  • Annually
 99401 with diagnosis codes Z30.011- Z30.09, Z30.40-Z30.42, Z30.431, Z30.49, Z30.9, Z30.44, Z30.45, or Z30.46  

STERILIZATION

  • Female only
  • One procedure per lifetime

58600, 58661, 58605, 58611, 58615, 58670, 58671, 58700, 00840, 00851 with diagnosis code Z30.2

6/4/25- Add 00840

  

CONTRACEPTIVE METHODS- MEDICAL

 

96372, A4261, A4266, 11976, 11981, 11982, 11983, 57170, 58300, 58301, J1050, J7294, J7295, J7296, J7297, J7298, J7300, J7301, J7304, J7306, J7307, S4981, S4989, with diagnosis codes Z30.013- Z30.019, Z30.09, Z30.40, Z30.42, Z30.430, Z30.431, Z30.432, Z30.433, Z30.44, Z30.45, Z30.46, Z30.49, Z30.9

1/1/24 Added 96372 (for Depo-Provera administration)

 Note: (For dates of services prior to 1/1/24) Injection code 96372 if Depo-Provera was given was not added to HCR Women’s Preventive Coding since we are unable to tie it back to a matching procedure to provide accurate coverage

CONTRACEPTIVE METHODS- MOBILE APP

Effective 4/1/2024

  • Females only
  • One 12-month subscription per year
 A9293 with Z30.8, Z30.9, Z30.02, Z30.09 Note: Coverage includes member reimbursement for the cost of FDA-approved, cleared, or granted mobile device applications for use as contraception consistent with the FDA-approved, cleared, or granted indication. Members must submit a Medical Expense Claim Form with an itemized receipt and prescription for reimbursement. 

CONTRACEPTIVE METHODS- PHARMACY

  • Generic only
 To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled by the pharmacy Brand coverage may be available, contact Customer Service for additional information

BREASTFEEDING – COUNSELING AND SUPPORT

  • Five per year in conjunction with birth
 99402-99404 with modifier TH and diagnosis code Z39.1  

BREASTFEEDING – SUPPLIES

(Pumps and Accessories)

 

Pumps – E0602, E0603 with type service H for rental or G for purchase, E0604 (rental only)

Accessories – A4281, A4282, A4283, A4284, A4285, A4286, A4287, A4288

1/1/2024 Added code A4287

10/1/2025 Added A4288

E0603 – one pump allowed per pregnancy

The requirement to cover the rental or purchase of breastfeeding equipment without cost sharing extends for the duration of breastfeeding, provided the individual remains continuously enrolled in the plan or coverage.

SCREENING AND COUNSELING FOR INTERPERSONAL AND DOMESTIC VIOLENCE

  • Females only beginning at age 10
  • Annually

99401-99404 with diagnosis codes Z65.9, Z69.010-Z69.12, Z69.82, Z71.89

 

PREVENTING OBESITY IN MIDLIFE WOMEN

  • Women ages 40-60 years
  • 1 hour per year (any combination of 99401- 99404)
 99401, 99402, 99403, 99404 with diagnosis Z68.1, Z68.20, Z68.21, Z68.22, Z68.23, Z68.24, Z68.25, Z68.26, Z68.27, Z68.28, Z68.29  

PATIENT NAVIGATION SERVICES FOR BREAST & CERVICAL CANCER SCREENING

Effective 1/1/26

 Included in preventive office visit  

 

ROUTINE PRENATAL DIAGNOSIS CODES O21.0, O22.00-O22.13, O22.40-O22.43, O22.8X1-O22.8X9, O42.10-O42.119, O47.00-O48.0, O92.011-O92.019, O92.111-O92.119, O92.20-O92.3, O92.5-O92.79, Z03.71-Z03.79, Z32.01, Z33.1, Z33.3, Z34.00-Z36.5, Z36.81-Z36.9, Z64.0
HIGH RISK PRENATAL DIAGNOSIS CODES 

O00-O07.4, O09.00-O10.019, O10.111-O10.119, O10.211-O10.219, O10.311-O10.319, O10.411-O10.419, O10.911-O10.919, O11.1-O15.03, O15.9-O20.9, O21.1- O21.9, O22.20-O22.33, O22.50-O22.53, O22.90-O24.019, O24.111-O24.119, O24.311-O24.319, O24.410-O24.419, O24.811-O24.819, O24.911-O24.919, O25.10- O25.13, O26.00-O26.43, O26.611-O26.619, O26.711-O26.719, O26.811-O26.93, O29.011-O30.93, O31.00X-O32.9XX (7th character 0,1,2,3,4,5, or 9), O33.0- O33.2, O33.3XX-O33.6XX (7th character 0,1,2,3,4,5, or 9), O33.7XX0-O34.93, O35.0XX-O41.93X (7th Character 0,1,2,3,4,5, or 9), O42.00-O42.019, O42.90- O42.919, O43.011-O46.93, O48.1-O60.03, O60.10X (7th character 0,1,2,3,4,5, or 9), O60.20X (7th character 0,1,2,3,4,5,or 9), O91.011-O91.019, O91.111-O91.119, O91.211-O91.219, O91.23, O98.011-O98.019, O98.111-O98.119, O98.211-O98.219, O98.311-O98.319, O98.411-O98.419, O98.511-O98.519, O98.611-O98.619, O98.711-O98.719, O98.811-O98.819, O98.911-O98.919, O99.011-O99.019, O99.111-O99.119, O99.210-O99.213, O99.280-O99.283, O99.310-O99.313, O99.320-O99.323, O99.330-O99.333, O99.340-O99.343, O99.350-O99.353, O99.411-O99.419, O99.511-O99.519, O99.611-O99.619, O99.711-O99.719, O99.810, O99.820, O99.830, O99.840-O99.843, O99.89, O9A.111-O9A.119, O9A.211-O9A.219, O9A.311-O9A.319, O9A.411-O9A.419, O9A.511-O9A.519, Z33.2

10/1/22 add O35.00X0, O35.00X1, O35.00X2, O35.00X3, O35.00X4, O35.00X5, O35.00X9, O35.01X0, O35.01X1, O35.01X2, O35.01X3, O35.01X4, O35.01X5, O35.01X9, O35.02X0, O35.02X1, O35.02X2, O35.02X3, O35.02X4, O35.02X5, O35.02X9, O35.03X0, O35.03X1, O35.03X2, O35.03X3, O35.03X4, O35.03X5, O35.03X9, O35.04X0, O35.04X1, O35.04X2, O35.04X3, O35.04X4, O35.04X5, O35.04X9, O35.05X0, O35.05X1, O35.05X2, O35.05X3, O35.05X4, O35.05X5, O35.05X9, O35.06X0, O35.06X1, O35.06X2, O35.06X3, O35.06X4, O35.06X5, O35.06X9, O35.07X0, O35.07X1, O35.07X2, O35.07X3, O35.07X4, O35.07X5, O35.07X9, O35.08X0, O35.08X1, O35.08X2, O35.08X3, O35.08X4, O35.08X5, O35.08X9, O35.09X0, O35.09X1, O35.09X2, O35.09X3, O35.09X4, O35.09X5, O35.09X9, O35.10X0, O35.10X1, O35.10X2, O35.10X3, O35.10X4, O35.10X5, O35.10X9, O35.11X0, O35.11X1, O35.11X2, O35.11X3, O35.11X4, O35.11X5, O35.11X9, O35.12X0, O35.12X1, O35.12X2, O35.12X3, O35.12X4, O35.12X5, O35.12X9, O35.13X0, O35.13X1, O35.13X2, O35.13X3, O35.13X4, O35.13X5, O35.13X9, O35.14X0, O35.14X1, O35.14X2, O35.14X3, O35.14X4, O35.14X5, O35.14X9, O35.15X0, O35.15X1, O35.15X2, O35.15X3, O35.15X4, O35.15X5, O35.15X9, O35.19X0, O35.19X1, O35.19X2, O35.19X3, O35.19X4, O35.19X5, O35.19X9, O35. AXX0, O35.AXX1, O35.AXX2, O35.AXX3, O35.AXX4, O35.AXX5, O35.AXX9, O35.BXX0, O35.BXX1, O35.BXX2, O35.BXX3, O35.BXX4, O35.BXX5, O35.BXX9, O35.CXX0, O35.CXX1, O35.CXX2, O35.CXX3, O35.CXX4, O35.CXX5, O35.CXX9, O35.DXX0, O35.DXX1, O35.DXX2, O35.DXX3, O35.DXX4, O35.DXX5, O35.DXX9, O35.EXX0, O35.EXX1, O35.EXX2, O35. EXX3, O35.EXX4, O35.EXX5, O35.EXX9, O35.FXX0, O35.FXX1, O35.FXX2, O35.FXX3, O35.FXX4, O35.FXX5, O35.FXX9, O35.GXX0, O35.GXX1, O35.GXX2, O35.GXX3, O35.GXX4, O35.GXX5, O35.GXX9, O35.HXX0, O35.HXX1, O35.HXX2, O35.HXX3, O35.HXX4, O35.HXX5, O35.HXX9 10/1/22 remove O350XX0, O350XX1, O350XX2, O350XX3, O350XX4, O350XX5, O350XX9, O351XX0, O351XX1, O351XX2, O351XX3, O351XX4, O351XX5, O351XX9

10/1/23 Add O26.641, O26.642, O26.643, O26.649

 

 

The Patient Protection and Affordable Care Act (ACA) defines preventive care services as follows:

  • Items or services recommended with an A or B rating by the U.S. Preventive Services Task Force.

  • Immunization recommended by the Advisory Committee on Immunization Practices (ACIP) of the Center for Disease Control (CDC). (children , adolescent, and adult)

  • Preventive care and screening for infants, children, and adolescents supported by the Health Resources and Services Administration (Bright Futures).

  • Preventive care and screening for women supported by the Health Resources and Service Administration. (These guidelines have not been defined yet.)

 

All providers must use the codes provided in this document when filing claims for healthcare reform mandated preventive services for a Blue Plan member.

 

If the preventive services section of your plan's benefit booklet refers to any of the preventive services and immunizations in this document, they will be covered by your health plan. However, a group may decide to delay the effective date for coverage until the group's plan year for any new preventive services and immunizations recently added to this list. If a plan covers these services, please be aware that in some cases, routine preventive services and routine immunizations may be billed separately from an office or other facility visit. In that case, the applicable office visit or outpatient facility copayments described in the physician benefits and outpatient hospital benefits sections of the benefit booklet may apply. In any case, applicable office visit or facility copayments may still apply when the primary purpose for a visit is not routine preventive services and/or routine immunizations. If you have any questions about a plan’s benefits, you may call our Customer Service Department at the number on the back of the ID card.

Revised 12/25 LR