Health Care Reform Preventive Services Coding Guide The Patient Protection and Affordable Care Act (PPACA) and the Health Care and Education Reconciliation Act of 2010 (HCERA) has designated the services listed below as preventive benefits and available with no cost-sharing when provided by an in-network provider for members of non-grandfathered health plans. In addition to the services listed below, your patient may have additional preventive care benefits covered under their health plan that may or may not be covered at 100%. Your patient should check their benefit booklet for details on these additional preventive care benefits. The following tables provide a quick reference guide for submitting claims for preventive services with a “well-person” diagnosis code as the primary (first) diagnosis on the claim. This information is intended as a reference tool for your convenience and is not a guarantee of payment. This guide is subject to change based on new or revised laws and/or regulations, additional guidance and/or BCBSNC medical policy. IMPORTANT INFORMATION: Services must be billed with the appropriate diagnosis, at the line level of the claim (Block 24E), pursuant to industry standard coding guidelines. Preventive or screening services are intended for those who currently exhibit no signs or symptoms of disease. Services otherwise deemed preventive that are received in an inpatient setting, an emergency room, or that include additional procedures or diagnostic services may be subject to copayment, deductible and coinsurance. Submitting screening service codes (CPT, HCPCs, ICD-9 or ICD-10) when signs or symptoms are present constitutes inappropriate coding which could result in recoupment of monies paid to the provider for those services. Additionally, these services are subject to certain limitations depending on medical necessity and other reasonable medical management techniques. If you have questions, please contact the Provider Blue Line at 1-800-214-4844. Grade A and B Recommendations of U.S. Preventive Services Task Force (USPSTF) currently effective unless otherwise noted CPT or HCPCS ICD-10 Diagnosis Comments 1.Screening for Abdominal Aortic G0389 Z13.6 Aneurysm Effective (one time screening for abdominal aortic 1/1/2017:76706 aneurysm by ultrasonography in men ages 65-75 who have ever smoked) 2.Screening and counseling to reduce 99408, 99409, Z13.89, F10.10, F10.120, F10.129 These codes are to be used in the absence of a wellness alcohol misuse The USPSTF recommends G0442 or G0443, visit. that clinicians screen adults aged 18 years G0396, G0397 or older for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse. Aspirin to prevent cardiovascular disease Not applicable, Not applicable, administered through Pharmacy OTC Aspirin (81 mg) is dispensed to member with a and colorectal cancer in men and women administered through physician order with no cost-sharing. (Low-dose aspirin use for the primary Pharmacy prevention of cardiovascular disease (CVD) and colorectal cancer (CRC) in adults aged 50 to 59 years who 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, and are willing to take low- dose aspirin daily for at least 10 years.) 4.Screening for bacteriuria (screening for 87081, 87084, Z34.00, Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82, Dipstick or other urinalysis included in global maternity asymptomatic bacteriuria with urine culture 87086 or 87088 Z34.83, Z34.90, Z34.91, Z34.92, Z34.93, Z33.1, O09.00, visits. Only urine culture part of preventive services for pregnant women at 12 - 16 weeks' O09.01, O09.02, O09.03, O09.10, O09.11, O09.12, mandate. gestation or at the first prenatal visit, if later) O09.13, O09.291, O09.292,O09.293, O09.299, O09.40, NOTE: Z33.1 is not an acceptable principle O09.41, O09.42, O09.43, O09.211, O09.212,O09.213, diagnosis code. O09.219, O09.30, O09.31, O09.32, O09.33, O09.511, O09.512,O09.513, O09.519, O09.521 O09.522,O09.523, O09.529,O09.611, O09.612,O09.613, O09.619,O09.621, O09.622,O09.623, O09.629,O09.811, O09.812,O09.813, O09.819,09.821,O09.822,O09.823,O09.829,O36.80X0,O3 6.80X1,O36.80X2, O36.80X3,O36.80X4, O36.80X5,O36.80X9, O09.891, O09.892, O09.893, O09.899, O09.70, O09.71, O09.72, O09.73, O09.90, O09.91, O09.92, O09.93 O09.A0, O09.A1, O09.A2, O09.A3 5.Screening for high blood pressure 99385 - 99387 or Z13.6 or other wellness exam diagnosis code Part of wellness office visit. (Recommends screening for high blood 99395-99397 For coverage of ABPM or HBPM diagnosis code R03.0 is Effective 1/1/2017, ambulatory blood pressure pressure in adults aged 18 years or older. For ambulatory required monitoring(ABPM) or home blood pressure monitors The USPSTF recommends obtaining blood pressure (HBPM) for confirmation of high blood pressure is measurements outside of the clinical setting monitoring use covered at 100%. Home blood pressure monitors must for diagnostic confirmation before starting 93784, 93786, be purchased from an in-network durable medical treatment) 93788, 93790 equipment (DME) vendor. For home blood pressure monitor use A4670 6.Counseling related to BRCA screening Referrals for Z80.3, Z80.41, Z85.07, Z85.3, Z85.43, Z85.44, Z85.46, or Services for BRCA 1/BRCA 2 testing will be provided (Recommends that primary care providers counseling included Z31.5, Z71.83 (effective 10/1/17) with no cost sharing to appropriate groups when the screen women who have family members in wellness visit medical policy criteria are met. with breast, ovarian, tubal, or peritoneal codes 99385-99387, See BCBSNC Medical Policy: Genetic Testing for Breast cancer with 1 of several screening tools 99395-99397 and Ovarian Cancer designed to identify a family history that may Counseling services 99401-99404 are to be used in the absence of a wellness be associated with an increased risk for use 96040, 99401, visit. potentially harmful mutations in breast 99402, 99403, cancer susceptibility genes (BRCA 1 or 99404, or S0265 BRCA 2). Women with positive screening Genetic testing use results should receive generic counseling 81211, 81212, and, if indicated after counseling, BRCA 81213, 81214, testing.) 81215, 81216, 81217 or 81162 An Independent licensee of the Blue Cross and Blue Shield Association. January 1, 2018 Health Care Reform Preventive Services Coding Guide Grade A and B Recommendations of U.S. Preventive Services Task Force (USPSTF) currently effective unless otherwise noted CPT or HCPCS ICD-10 Diagnosis Comments 7.Screening for breast cancer G0202, 77057, Z12.31, Z12.39 If the patient has had an abnormal mammogram in the [mammography] 77052 past, subsequent routine mammograms may be coded (for women aged 40 or over every 1-2 yrs , Effective as diagnostic: 77061, 77062, 77065, 77066, G0279 with with or without clinical breast examination) 1/1/2017:77067 a diagnosis reflective of the abnormality. Effective 6/1/17:77063 8.Chemoprevention of breast cancer 99401 - 99402 or is Z15.01, Z80.3, D24.1, D24.2, D24.9, N60.81, N60.82, This recommendation applies to asymptomatic women (Recommends that clinicians engage in included in wellness N60.89 aged 35 years or older without a prior diagnosis of breast shared, informed decision making with visit 99385-99387, cancer, ductal carcinoma in situ, or lobular carcinoma in women who are at increased risk for breast 99395-99397 situ. Generic risk-reducing medications are dispensed to cancer about medications to reduce their member with a physician order with no cost-sharing. risk. For women who are at increased risk For members who have swallowing problems or may for breast cancer and at low risk for adverse have an intolerance to generic products, brand products medication effects, clinicians should offer to may also be made available by completing the Copay prescribe risk-reducing medications, such as Waiver Form and faxing it to the number on the bottom tamoxifen or raloxifene) of the document. 99401-99404 are to be used in the absence of a wellness visit. NOTE: Z15.01 is not an acceptable principle diagnosis 9.Interventions to support breast feeding 99401 - 99403 or part O30.93, Z34.03, Z34.83, Z34.93, Z39.1 99401-99403 are to be used in the absence of a wellness (interventions during pregnancy and after of other office visit visit. birth to promote and support breastfeeding) 10.Screening for cervical cancer 88141, 88142, Z00.00, Z00.01, Z01.411, Z01.419, Z01.42, Z12.4, Z11.51 This recommendation does not apply to women who (in women ages 21 to 65 yrs with cytology 88143, 88147, have received a diagnosis of a high-grade precancerous (pap smear) every 3 yrs or, for women ages 88148, 88150, cervical lesion or cervical cancer, women with in utero 30-65 yrs who want to lengthen the 88152, 88153, exposure to diethylstilbestrol, or women who are screening interval, screening with a 88154, 88164, immunocompromised (such as those who are HIV combination of cytology and human 88165, 88166, positive). papillomavirus (HPV) testing every 5 yrs) 88167, 88174, 88175, 87623, 87624, 87625, G0101, G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001 11.Screening for chlamydial infection in 87270, 87320, Z34.00, Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82, NOTE: Z33.1 is not an acceptable principle diagnosis non-pregnant and pregnant women (for 87490, 87491 and Z34.83, Z34.90, Z34.91, Z34.92, Z34.93, Z33.1, O09.00, code.