BlueCross and BlueShield of Montana Medical Policy/Codes
Preventive Care Services
Chapter: Administrative
Current Effective Date: February 15, 2014
Original Effective Date: October 01, 2010
Publish Date: January 15, 2014
Revised Dates: February 4, 2011; March 21, 2011; September 23, 2013; January 15, 2014
Description

Preventive care or preventive medicine refers to measures or services taken to promote helah and early detection/prevention of disease(s) and injuries rather than treating them and/or curing them.

Preventive care may include examinations and screening tests tailored to an individual’s age, health, and family history.

What is the Patient Protection and Affordable Care Act?

The Patient Protection and Affordable Care Act (PPACA), also known as Affordable Care Act (ACA) or Health Care Reform, is a U.S. Federal Statute that was signed into law on March 23, 2010. Together with the Health Care and Education Reconciliation Act of 2010, it represents significant change in government regulations of the U.S. healthcare system. The law includes a large number of health-related provisions that would become effective over the four years since being signed into law, including preventive care services. Effective by January 1, 2018, all existing select health insurance plans must cover approved preventive care and checkups without cost-sharing, such as co-payments, co-insurance, or deductibles. Grandfathered plans are exempt from this requirement.

What has been the history or timeline for Health Care Reform?

The current Health Care Reform or ACA arose from the 1930’s to the present as a method of providing health care to more and more individuals who could not afford medical care.

  • 1965 – President Lyndon Johnson enacted legislation that introduced Medicare, covering both hospital and general medical insurance for senior citizens paid for by a Federal employment tax over the working life of the retiree; and, Medicaid permitted the Federal government to partially fund a program for the poor, with the program managed and co-financed by the individual states.
  • 1985 – The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) amended the Employee Retirement Income Security Act of 1974 (ERISA) to give some employees the ability to continue health insurance coverage after leaving employment.
  • 1993 – Increasing concerns over Health Care Reform had been brought forward for debate and resolution by President Bill Clinton. However, the 1993 Health Care Plan was proposed and subsequently never enacted into law.
  • 1996 – The Health Insurance Portability and Accountability Act (HIPAA) was enacted by President Bill Clinton. Title I protects health insurance coverage for workers and their families when they change or lose their jobs. Title II requires establishment of national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers. Title II includes the definitions, procedures, and guidelines for maintaining privacy and security of individually identifiable health care information, as well as creating programs to control fraud and abuse within the health care system.
  • 1997 – The State Children's Health Insurance Program, or SCHIP, was established by the federal government in 1997 to provide health insurance to children in families at or below 200 percent of the federal poverty line.
  • 2010 – The PPACA or ACA, as described above, was enacted by President Barack Obama. By January 1, 2020, all facets of ACA shall have been phased in and operational.

Glossary of Terms

  • Cost Sharing – The amount of money paid by the patient for health services, such as co-insurance, deductibles, co-payments.
  • Evidence-Based Medicine – Is a term applied to medical practices that have been thoroughly evaluated by peer-reviewed journals, and have been deemed safe and effective by the scientific community. Ratings or Grading may have been assigned to the medical practice being reviewed.
  • Grandfathering – Allows health plans to remain as is and not be required to implement certain changes or aspects of ACA’s new rules and protections. These plans were in existence prior to March 23, 2010. Under this provision, health plans are allowed to make routine changes to their policies, such as cost-adjustments, adding new benefits, some adjustments to existing benefits, voluntarily adopting new consumer protections, or making changes to comply with Federal or State laws.
  • Network (Preferred) Provider – A provider, such as a hospital or doctor, who has contracted with the health plan
  • Non-Grandfathering – Health plan has reduced or changed the individual’s benefits or increased the cost to the consumer.
  • Out-of-Network (Non-Preferred) Provider – A provider, such as a hospital or doctor, who has not contracted with the health plan.
  • Out-of-Pocket Costs – Health care costs that are not covered by the health care plan, such as deductibles, co-payments, and deductibles. Out-of-Pocket costs do not include insurance premiums.
  • Prevention for Adults – Includes certain preventive care measures for adults as recommended by the Health Resource and Services Administration with the U.S. Preventive Services Task Force (USPSTF), such as abdominal aortic aneurysm screening for men, depression screening, sexually transmitted infections (STI) prevention counseling, and many other screenings, services, and/or counseling on a variety of subjects.
  • Prevention for Children – Includes preventive care guidelines for children from birth to age 21 developed by the Health Resources and Services Administration with the American Academy of Pediatrics (AAP). These services include regular pediatrician (primary care provider) visits, developmental assessments, immunizations, and screening and counseling to address obesity.
  • Prevention for Women (and Pregnant Women) – Includes certain preventive care measures for women as recommended by the Health Resource and Services Administration with the U.S. Preventive Services Task Force (USPSTF), such as mammograms, screening for cervical cancer, and many other screenings, services, and/or counseling on a variety of subjects.
  • Routine Immunizations – Vaccines that are considered routine for use with children, adolescents, and adults, and range from childhood immunizations to periodic tetanus shots for adults. The immunizations are recommended by the American Academy of Family Practice (AAFP), American Academy of Pediatrics (AAP), or Advisory Committee on Immunization Practices (ACIP)-(part of the Center for Disease Control and Prevention - the CDC) Refer to Medical Policy, ADM1001.025, Recommended Immunization Schedule for Children and Adults for more information.
  • U.S. Preventive Services Task Force (USPSTR or Task Force) – Is an independent group of national experts in prevention and evidence-based medicine that works to improve the health of all Americans by making evidence-based recommendations about clinical preventive services such as screenings, counseling services, or preventive medications. The USPSTF is made up of 16 volunteer members who come from the fields of preventive medicine and primary care, including internal medicine, family medicine, pediatrics, behavioral health, obstetrics or gynecology, and nursing. All members volunteer their time to serve on the USPSTF, and most are practicing clinicians.
Policy

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coverage

Certain preventive care services may be considered eligible for coverage under the member’s benefit plan as required by the U.S. Federal Affordable Care Act and/or an applicable state mandate. In general, these services include, but are not limited to, screenings, immunizations, and other types of care, as recommended by the U.S. Federal Government.

NOTE:  These services are not subject to application of cost-sharing, such as co-payments, co-insurance or deductibles when they may be considered eligible for coverage and are provided by a network provider.

Applicable preventive care services, along with the associated procedure codes, are listed in the grid below.

Preventive Service Benefit

Procedure Codes

(CPT/HCPCS/ICD-9 procedure codes)

Abdominal Aortic Aneurysm (AAA) Screening

76770, 76775, G0389

Alcohol Misuse Screening and  Counseling: Adults and Pregnant Women

99385-99387, 99395-99397, 99408, 99409, G0396, G0442, G0443

Anemia Screening:

Pregnant Women

80055, 85004-85041, G0306, G0307

Aspirin Usage:

Adults

NOTE: For the prevention of cardiovascular disease (CVD) in men ages 45 to 79 and in women ages 55-79, when there potential benefit due to a reduction in myocardial infarctions outweighs the potential harm due to an increase in gastrointestinal hemorrhage. Physician prescription required. 

None

Bacteriuria Screening:

Pregnant Women

87086, 87088

Blood Pressure Screening

99385-99387, 99395-99397

BRCA Counseling

NOTE: Genetic counseling and evaluation for BRCA testing where family history is associated with increased risk

96040, 99395-99397, 99398-99397, 99401-99404, S0265

 

 

Breast Cancer Screening or Screening Mammography

77051, 77052, 77055-77057, G0202

Breast Cancer Evaluation of Chemoprevention

99385-99387, 99395-99397, 99401-99404

Breastfeeding Support, Supplies and Counseling

99401-99404, 99411-99412, A4281-A4286, E0602, E0603, E0604, S9443

Cervical Cancer or Cervical Dysplasia Screening

Preventive Exam Codes: 99383-99387, 99393-99397, G0101

Pap Smear screening: 88141-88155, 88164-88167, 88174-88175, G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091

HPV (human papilloma virus) Screening: 87620-87622

Chlamydia Infection Screening

 

87110, 87270, 87320, 87490-87492, 87810, G0450

Cholesterol Screening

80061, 82465, 83700, 83718, 83719, 83721, 84478

Colorectal Cancer Screening

NOTE: Anesthesia for colonoscopy may also be covered with no member cost-sharing.

Fecal Occult Blood Testing (FOBT): 82270, 82274, G0328

Colonoscopy: 44388-44394, 44397, 45378-45387, 45391, 45392, G0105, G012, 45.22, 45.23

Flexible Sigmoidoscopy: 45330-45335, 45337-45342, 45345, G0104, 45.24

Contraceptive Methods Including Sterilization

NOTE: Contraception methods that require a prescription may be covered under the patient’s medical or pharmacy benefit. For details about pharmacy benefit coverage for contraception, contact the number on the patient’s BCBS member card. A patient’s pharmacy benefit may be managed by a company other than BCBS.

Contraceptive Implant: 11976, 11981, J1051, J1055, J7301, J7302, J7306, J7307, S4981

Cervical Cap or Diaphragm Fitting: 57170 IUD: 58300, 58301, J7300, Q0090, S4989

Female Sterilization: 58565, 58600, 58605, 58611, 58615, 58670, 58671, A4264.

Depression Screening for Adults and Adolescents Ages 12-18

99384-99387, 99394-99397, G0444

Developmental & Behavioral Assessments: Children & Adolescents

96110, 99381-99384, 99391-99394

Diabetes Screening

82947, 82948, 82950, 82951, 83036, 82952

Dyslipidemia Screening:

Children and Adolescents at Higher Risk of Lipid Disorder

80061, 82465, 83700, 83718, 83719, 83721, 84478

Falls Prevention:

Older Adults:

NOTE: Exercise and physical therapy recommended to prevent falls in community-dwelling adults age 65 years and older who are at risk for falls.

97001-97004, 97110, 97112, 97116, 97150, 97530

Folic Acid

NOTE: Coverage does not include folic acid; coverage only includes counseling about the use of folic acid to prevent neural tube defects.

99384-99386, 99394-99396, 99401-99404, 99411, 99412

 

Gestational Diabetes Screening:

Pregnant Women

82947, 82948, 82950-82952, 83036

 

Gonorrhea Screening:

Pregnant and Non-Pregnant Women

87081, 87590-87592, 87850, G0450

Health Diet or Nutrition Counseling

97802-97804, 99401-99404, G0270, G0271, S9449, S9452, S9470

Hearing Screening:

Newborns

NOTE: Further evaluation recommended as a result of a hearing screening test is not considered preventive and may not be covered without member cost-sharing.

92585-92588

Hearing Screening:

Children & Adolescents

NOTE: Further evaluation recommended as a result of a hearing screening test is not considered preventive and may not be covered without member cost-sharing.

92551, 99381-99384, 99391-99384, V5008

Hematocrit or Hemoglobin Screening: Children and Adolescents

85004, 85013, 85014, 85018, 85025, 85027, G0306, G0307

Hepatitis B Screening:

Pregnant Women

80055, 87340, 87341, G0450

Hepatitis C Screening:

Adults

NOTE: Screening for Hepatitis C (HCV) infection in person at high-risk for infection. One-time screening offered for HCV infection to adults born between 1945 and 1965.

86804

HIV Screening: Adults and Pregnant Women, Children & Adolescents

86689, 86701-86703, 87389-87391, G0432, G0433, G0435, S3645

Hypothyroidism Screening:

Newborns

84436, 84437, 84443

Immunizations:

Adults -

  • Hepatitis A
  • Hepatitis B
  • Human Papillomavirus (HPV)
  • Influenza (Flu)
  • Measles, Mumps, Rubella
  • Meningococcal
  • Pneumococcal
  • Tetanus, Diphtheria, Pertussis
  • Varicella (chickenpox)
  • Zoster

NOTE: Other vaccines may be covered without member cost-sharing by BCBS. Refer to Medical Policy, ADM1001.025, Recommended Immunization Schedule for Children and Adults for more information.

90471-90474, 90632, 90636, 90649, 90650, 90656, 90658, 90660-90663, 90672, 90673, 90703-90707, 90709, 90710, 90714-90716, 90718, 90719, 90732-90734, 90736, 90740, 90743, 90746, 90747, G0008, G0009, J3530, Q2033, Q2035-Q2039

Immunizations:

Children & Adolescents -

  • Tetanus, Diphtheria, Pertussis
  • Haemophilus influenza type B
  • Hepatitis A
  • Hepatitis B
  • Human Papillomavirus (HPV)
  • Influenza (Flu)
  • Measles, Mumps, Rubella
  • Meningococcal
  • Pneumococcal
  • Inactivated Poliovirus
  • Rotavirus
  • Varicella (chickenpox)

NOTE: Other vaccines may be covered without member cost-sharing by BCBS. Refer to Medical Policy, ADM1001.025, Recommended Immunization Schedule for Children and Adults for more information.

90460-90474, 90632-90634, 90636, 90645-90650, 90655-90658, 90660-90663, 90669, 90673, 90680, 90681, 90696, 90698, 90700-90710, 90713-90716, 90718-90721, 90723, 90732-90734, 90740, 90743, 90744, 90746-90748, J3530, Q2035-Q2039, S0195

Intimate Partner Violence Screening:

Women of child-bearing age

NOTE: This applies to women who do not have signs or symptoms of abuse.

99201-99205, 99211-99215, 99384-99387, 99394-99397, 99401-99404, 99411, 99412, S0610, S0612, S0613

Lead Screening:

Children

83655

Obesity Screening and Counseling:

Adults and Children & Adolescents

Adults: 97802-97804, 99385-99387, 99395-99397, 99401-99404, 99411, 99412, 99078, G0047

Children: 99382-99385, 99391-99395, 99401-99404, 99411, 99412, 99078

Oral health in Preschool Children

NOTE: Services include prescription fluoride if water source is deficient in fluoride and evaluation of need for a dentist visit.

99381-99383, 99391-99393, 99401-99404, 99411, 99412

Osteoporosis Screening or Bone Density Test

76977, 77078-77081, 78350, 78351, G0130

PKU (phenylketonuria) Screening:

Newborns

84030

Preventive Care Visit (Adult) or Well-Woman Visit

99384-99387, 99394-99397, G0438, G0439

Prostate Cancer Screening

84152-84154, 99386, 99387, 99396, 99397

Rh Incompatibility Screening:

Pregnant Women

80055, 86850, 86870, 86900, 86901

 

Sexually Transmitted Infections (STIs) Prevention Counseling Including Syphilis, Gonorrhea and Chlamydia:

Adults and Adolescents who are Sexually Active

99384-99387, 99394-99395, 99401-99404, 99411, 99412

Sickle Cell Disease Screening:

Newborns

83020, 83021, S3620

Skin Cancer Behavioral Health Counseling:

NOTE: Counseling for children, adolescents, and young adults ages 10 to 24 years who have fair skin about minimizing their exposure to ultraviolet radiation to reduce risk for skin cancer.

None

Syphilis Screening:

Adults and Pregnant Women

80055, 86592, 86593, G0450

Tobacco Use & Cessation Counseling:

Adults and Pregnant Women

99406, 99407, G0436, G0437, G9016, S9075, S9453

Tuberculin Testing

86480, 86580

Vision Acuity Screening:

Children and Adolescents

NOTE: Visual acuity screening and screening for amblyopia and strabismus are covered as preventive care services. Further evaluation recommended as a result of the screening is not considered to be a preventive service and may not be covered without member cost-sharing.

99172, 99173, 0333T

Vitamin D Supplementation

NOTE: Prevention of falls in adults age 65 and older who are at risk for falls. Physician prescription required. 

None

Well Baby or Well Child Exam

99381-99384, 99391-99394

NOTE:  There may be a more specific Health Care Services Corporation (HCSC) medical policy that addresses preventive care services. Please refer to that specific policy for coverage information, such as routine immunization or vaccine coverage – ADM1001.025, Recommended Immunization Schedule for Children and Adults.

NOTE: Many of the services listed above may be performed for indications OTHER THAN preventive care. In these situations, services may be covered by another provision of the individual’s benefit plan and subject to applicable cost-sharing.

Policy Guidelines

Refer to the most current CPT® Manual, the HCPCS Manual and/or the ICD-9 Manual for the descriptions or definitions of the codes listed within the Medical Policy. Codes are subject to change.

For services to be covered as a preventive care benefit, the claim must include the appropriate procedure code plus a preventive diagnosis for the service. The majority of the services listed do not require a specific diagnosis code; the claim should accurately reflect the reason for the service.

NOTE: HCPCS Code Q0090 will not become effective for utilization for reporting or claims processing until 7/1/2013.

Rationale

The preventive care services for children and adults shall follow the recommendations approved by the:

The preventive care service recommendations adopted by the CDC, ACIP, AAP, and AAFP, are consistent with the other groups listed that promote preventive health services to patients of all ages. Health care providers may provide education to their patients or the patient's parents/guardians about preventive services and immunizations in general and the proposed schedule of screening/services and/or immunizations due.

Coding

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps. 

ICD-9 Codes

Too numerous to list.

ICD-10 Codes

Too numerous to list.

Procedural Codes: 11976, 11981, 44388-44394, 44397, 45330-45335, 45337-45342, 45345, 45378-45387, 45391, 45392, 57170, 58300, 58301, 58565, 58600, 58605, 58611, 58615, 58670, 58671, 77078-77082, 78350, 78351, 76770, 76775, 76977, 77051, 77052, 77055-77057, 80055, 80061, 80055, 82270, 82274, 82465, 82947, 82948, 82950-82952, 83020, 83021, 83036, 83655, 83700, 83718, 83719, 83721, 84030, 84152-84154, 84436, 84437, 84443, 84478, 85004-85041, 86480, 86580, 86592, 86593, 86689, 86701-86703, 86804, 86850, 86870, 86900, 86901, 87081, 87086, 87088, 87110, 87270, 87320, 87340, 87341, 87389-87391, 87490-87492, 87590-87592, 87620-87622, 87810, 87850, 88141-88155, 88164-88167, 88174-88175, 90460-90474, 90632-90634, 90636, 90645-90650, 90655-90658, 90660-90663, 90669, 90672, 90673, 90680, 90681, 90696, 90698, 90700-90710, 90713-90716, 90719-90721, 90723, 90732-90734, 90736, 90740, 90743, 90744, 90746-90748, 92551, 92585-92588, 96040, 96110, 97001-97004, 97110, 97112, 97116, 97150, 97530, 97802-97804, 99078, 99172, 99173, 99201-99205, 99211-99215, 99395-99397, 99406-99408, 99409, 0333T, A4264, A4281-A4286, E0602, E0603, E0604, G0008, G0009, G0101, G0102, G0103, G0104, G0105, G0121, G0123, G0124, G0130, G0141, G0143-G0145, G0147, G0148, G0202, G0270, G0271, G0306, G0307, G0328, G0389, G0396, G0432, G0433, G0435-G0439, G0442, G0443, G0444, G0447, G0450, G9016, J1051, J1055, J3530, J3530, J7300, J7301, J7302, J7306, J7307, P3000, P3001, Q0090, Q0091, Q2033, Q2035-Q2039, S0195, S0265, S3620, S3645, S4981, S4989, S0610, S0612, S0613, S9075, S9449, S9452, S9453, S9470, V5008
References
  1. Affordable Health Care For America (2010 March 18). Prepared by the House Committees on Ways and Means, Energy and Commerce, and Education and Labor. Available at http://housedocs.house.gov (accessed on 2013 February 22).
  2. Guide to Clinical Preventive Services, 2012 – Recommendations of the U.S. Preventive Services Task Force. Prepared by the Agency for HealthCare Research and Quality from Recommendations by the U.S. Preventive Services Task Force. Available at http://www.ahrq.gov (accessed on 2013 February 22).
  3. USPSTF A and B Recommendations (2013 January). Prepared by the U.S. Preventive Services Task Force. Available at http://www.uspreventiveservicestaskforce.org (accessed on 2013 February 22).
  4. The Affordable Care Act and Wellness Programs (2013 February 25). Prepared by U.S. Federal Government. Available at http://www.healthcare.gov (accessed on 2013 February 25).
  5. The Guide to Community Preventive Services – The Community Guide, What Works to Promote Health 2013. Prepared by the Community Services Task Force of the Centers for Disease Control and Prevention. Available at http://www.cdc.gov (accessed on 2013 February 25).
History
February 4, 2011 Added the following to the description: "Preventive tests, as outlined below, must be ordered by the member’s treating health care provider, either as a component of a health maintenance evaluation, or as an evaluation of a medical condition for benefits to apply."
March 21, 2011 Revised to state: "BCBSMT is currently not reviewing claims to apply benefits based on this recommendation."
September 2013 Policy formatting and language revised.
February 2014 Document update based upon the U.S. Preventive Service Task Force A/B Recommendations for the U.S. Federal Affordable Care Act. The following was changed: 1.) Skin cancer behavioral counseling was added; 2.) Intimate partner violence screening was changed from domestic violence counseling; 3.) Prevention of falls for adults age 65 and older was added; 4.) Vitamin D supplementation was added; 4.) Gender and age groups added for aspirin recommendation to prevent cardiovascular disease; and 5.) Hepatitis C screening was added. CPT/HCPCS codes updated.
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Preventive Care Services