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Administrative Policy:
A004
Administrative Policy
Effective Date............................................ 04/15/2018
Next Review Date ..................................... 01/15/2019
Administrative Policy Number ......................... A004
Preventive Care Services
Table of Contents
Administrative Policy ........................................... 1
Wellness Examinations - General Description ..... 3
Frequency of Wellness Examinations .................. 3
Preventive Care Services that may be
provided during a Wellness Examination ......... 3
Preventive Care Screenings and Interventions
(Note: some services may be provided as
part of a wellness examination or at a
separate encounter) .......................................... 4
Coding/Billing Information .................................. 9
References .......................................................... 27
Related Coverage Resources
Bone Mineral Density Measurement
Breast Pumps
Cervical Cancer Screening Visualization Technologies
Colorectal Cancer Screening and Surveillance
Genetic Testing for Hereditary Cancer Susceptibility
Syndromes
Human Papillomavirus Vaccine
Mammography Screening
No Cost-Share Preventive Medications by Drug
Category
Prostate-Specific Antigen (PSA) Screening for
Prostate Cancer
Routine Immunizations
PURPOSE
Administrative Policies are intended to provide further information about the administration of standard Cigna benefit plans. In the event of a
conflict, a customer’s benefit plan document always supersedes the information in an Administrative Policy. Coverage determinations
require consideration of 1) the terms of the applicable benefit plan document; 2) any applicable laws/regulations; 3) any relevant collateral
source materials including Administrative Policies and; 4) the specific facts of the particular situation. Administrative Policies relate
exclusively to the administration of health benefit plans. Administrative Policies are not recommendations for treatment and should never be
used as treatment guidelines.
Administrative Policy
The Affordable Care Act (ACA) requires individual and group health plans to cover in-network preventive
services and immunizations without cost sharing (e.g., deductibles, coinsurance, copayments) unless the
plan qualifies under the grandfather provision or for an exemption. Coverage for preventive care services
other than those mandated by ACA is dependent on benefit plan language. For example, many benefit
plans specifically exclude immunizations that are for the purpose of travel or to protect against
occupational hazards and risks. Please refer to the applicable benefit plan language to determine benefit
availability and the terms, conditions and limitations of coverage. Services not covered under preventive
care services may be covered under another portion of the health plan.
Preventive care services are covered as required by the Affordable Care Act (ACA). The ACA designated
resources that identify the preventive services required for coverage are:
• United States Preventive Services Task Force (USPSTF) grade A or B recommendations
• Advisory Committee on Immunization Practices (ACIP) recommendations adopted by the Director of the
Center for Disease Control and Prevention (CDC)
• Health Resources and Services Administration (HRSA) supported comprehensive guidelines which
appear in any of the following sources:
o Periodicity schedule of the Bright Futures Recommendations for Pediatric Preventive Health Care
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Administrative Policy:
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o Uniform Panel of the Secretary’s Advisory Committee on Heritable Disorders in Newborns and
Children
o Guidelines specifically issued for women and adopted by HRSA
Preventive care services include wellness examinations and routine immunizations. Certain recommended
screenings identified by ACA are considered preventive care services for symptom-free or disease-free
individuals. Typically preventive care services must be provided by in-network health care professionals.
Ancillary services directly related to a screening colonoscopy or female sterilization procedures are considered
part of the preventive service. This includes a pre-procedure evaluation office visit, the facility fee, anesthesia
services, and pathology services.
According to the ACA, coverage of preventive services become effective upon a plan’s start or anniversary date
that is one year after the date the recommendation or guideline is issued. The USPSTF assigns each
recommendation a letter grade based on the strength of the evidence and the balance of benefits and harms of a
preventive service. If a Grade A or B recommendation changes to a Grade C or I, coverage must be provided
through the last day of the plan year. If a Grade A or B recommendation changes to a Grade D, or any previously
recommended service is subject to a safety recall or is otherwise determined to pose a significant safety concern,
there is no requirement to provide coverage through the last day of the plan year.
U.S.Preventive Services Task Force Letter Grade Descriptions
Grade A
The USPSTF recommends the service. There is high certainty that the net benefit is substantial.
Grade B
The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is
moderate certainty that the net benefit is moderate to substantial.
Grade C
The USPSTF recommends selectively offering or providing this service to individual patients based on
professional judgment and patient preferences. There is at least moderate certainty that the net benefit is
small
Grade D
The USPSTF recommends against the service. There is moderate or high certainty that the service has
no net benefit or that the harms outweigh the benefits
Grade I
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and
harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and
harms cannot be determined
The ACA states reasonable medical management techniques may be used to determine coverage limitations if a
recommendation or guideline does not specify the frequency, method, treatment, or setting for the provision of a
recommended preventive service. Reasonable medical management techniques may include precertification,
concurrent review, claim review, or similar practices to determine coverage limitations under the plan. These
established reasonable medical management techniques and practices may be utilized to determine frequency,
method, treatment or setting for the provision of a recommended preventive service.
Screening versus diagnostic, monitoring or surveillance testing
A positive result on a preventive screening exam does not alter its classification as a preventive service but does
influence how that service is classified when rendered in the future. For example, if a screening colonoscopy
performed on an asymptomatic individual without additional risk factors for colorectal cancer (e.g. ademomatous
polyps, inflammatory bowel disease) detects colorectal cancer or polyps, the purpose of the procedure remains
screening, even if polyps are removed during the preventive screening. However, once a diagnosis of colorectal
cancer or additional risk factors for colorectal cancer are identified, future colonoscopies will no longer be
considered preventive screening. Another example is a positive result on a screening stool -based
deoxyribonucleic acid (DNA) (i.e., Cologuard) test. A positive result should be followed by a diagnostic
colonoscopy which would not be considered preventive screening.
Reporting preventive care services
Preventive care services are reported with diagnosis and procedure codes which identify the services as
preventive and not for treatment of injury or illness. (Reference chart below). Age or frequency limits are utilized
for certain designated services (i.e., wellness exams, vision and hearing screening, services related to prevention
of falls, nutritional and genetic counseling). Preventive care services submitted with diagnosis codes that
represent treatment of illness or injury will be paid as applicable under normal medical benefits rather than
preventive care coverage.
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Administrative Policy:
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Modifier 33
Cigna does not process preventive care claims solely based on the presence of modifier 33, which was
developed by the industry in response to the ACA’s preventive service requirements. Preventive care services are
dependent upon claim submission using preventive diagnosis and procedure codes in order to be identified and
covered as preventive care services.
Additional Preventive Care Services
In addition to the designated services identified by ACA sources, adult wellness examinations, prostate cancer
screening, double contrast barium enema for colorectal cancer screening, digital breast tomosynthesis for breast
cancer screening, and venipuncture associated with preventive laboratory screenings are covered under the
benefit as preventive care services. Professional society statements and guidelines may vary and are not
considered part of ACA sources.
Wellness Examinations - General Description
Preventive medicine comprehensive evaluation and management services (i.e., Wellness examinations) for well-
baby, well-child and well-adult, including well-woman include:
• An age-and gender-appropriate history
• Physical examination
• Counseling/anticipatory guidance
• Risk factor reduction interventions
• The ordering of appropriate immunization(s) and laboratory/screening procedures
Frequency of Wellness Examinations
Ages 0 to age 5: According to the American
Academy of Pediatrics (AAP) Bright Futures
Periodicity Schedule
99381, 99382, 99391, 99392, 99461
Allowed with any diagnosis code
Ages 5 and above: Annual wellness examination;
annual well-woman exam; additional visits for
women’s services related to contraception
management
99383, 99384, 99385, 99386, 99387
99393, 99394, 99395, 99396, 99397
G0402, G0438, G0439, S0610, S0612, S0613
Allowed with any diagnosis code
Preventive Care Services that may be provided during a Wellness Examination
Administration/Interpretation of Health Risk
Assessment Instrument
Depression screening/Maternal Depression Screening
Alcohol and substance abuse/misuse
screening/counseling
Discussion of aspirin prophylaxis
Autism screening
Discussion of chemoprevention with women at risk for
breast cancer
Blood pressure measurement for high blood
pressure screening/Preeclampsia screening
Discussion/referral for genetic counseling/evaluation for
BRCA testing
Breast-feeding counseling/support
Domestic and interpersonal violence screening/counseling
Counseling/education to minimize exposure to
ultraviolet radiation
Hearing and vision screening
Counseling/education regarding FDA-approved
contraception methods for women including
counseling for continued adherence and follow-up,
management of side effects, and instruction in
fertility awareness-based methods including the
lactation amenorrhea method
Obesity screening/counseling regarding weight loss, healthy
diet and exercise
Counseling to prevent initiation of tobacco use
Psychosocial/Behavioral assessment
Counseling related to sexual behavior/sexually
transmitted infection (STI) prevention
Tobacco use screening/counseling
Critical congenital heart disease screening
Oral health assessment/discussion of water
fluoridation/referral to dental home
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Administrative Policy:
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Preventive Care Screenings and Interventions (Note: some services may be provided as
part of a wellness examination or at a separate encounter)
The following codes represent services that are NOT for treatment of illness or injury and should be submitted
with a designated wellness or maternity diagnosis code in the primary position on the claim form. Select a
Designated Wellness Code from pertinent Code Group.
Some services MAY require precertification or other reasonable medical management technique or practice depending on benefit plan design.
Abdominal Aortic Aneurysm Screening: Men, age
65-75 who have ever smoked
76700, 76705, 76770, 76775
Select Designated Wellness Code from Code Group 1
76706, G0389
Allowed with any diagnosis
Abnormal Blood Glucose and Type 2 Diabetes
Screening and Counseling: Adults, age 40-70 who
are overweight or obese
82947, 82948, 82950, 82951, 82952, 83036
Select Designated Wellness Code from Code Group 1
0403T, 0488T, G9873, G9874, G9875, G9876, G9877,
G9878, G9879, G9800, G9881, G9882, G9883, G9884,
G9885, G9890
Allowed with any diagnosis
Administration/Interpretation of Health Risk
Assessment Instrument
96160, 96161
Allowed with any diagnosis
Alcohol Misuse/Substance Abuse Screening and
Counseling: All adults, adolescents age 11-21
99408, 99409, G0396, G0397,G0442, G0443
Allowed with any diagnosis
Anemia, Iron Deficiency Anemia Screening:
Children age 12 months
85013, 85014, 85018, 85025, 85027, 85041, G0306, G0307
Select Designated Wellness Code from Code Group 1
Bacteriuria Screening: Pregnant women at 12-16
weeks gestation or at the first prenatal visit, if later
87086, 87088
Allowed with a Maternity Diagnosis Code
Bilirubin Screening: newborns
82247, 88720
Select Designated Wellness Code from Code Group 1
Breast Cancer/Ovarian Cancer risk assessment:
genetic counseling for women at risk
96040, S0265
Select Designated Wellness Code from Code Group 1
Subject to 3 visit limitation
BRCA1/BRCA2 Genetic Testing for susceptibility
to breast or ovarian cancer, if indicated: women
81162, 81211, 81212, 81213, 81214, 81215, 81216, 81217
Allowed with any diagnosis
(MAY require precertification or other reasonable medical management
technique or practice depending on benefit plan design)
Breast Cancer Screening: women age 40 and
older, with or without clinical breast exam, every 1-
2 years
Note: ACA utilizes the 2002 USPSTF
recommendations on breast cancer screening.
77065, 77066
Select Designated Wellness Code from Code Group 1
77063, 77067
Allowed with any diagnosis
Breast-feeding Support/Counseling during
pregnancy and after birth
99401, 99402, 99403, 99404, 99411, 99412, S9443
Allowed with any diagnosis
Breast-feeding Equipment/Supplies
A4281, A4282, A4283, A4284, A4285, A4286, E0602,
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E0603, E0604
Allowed with any diagnosis code
(E0604 MAY require precertification or other reasonable medical
management technique or practice depending on benefit plan design)
Requires a prescription and must be ordered through
CareCentrix, Cigna's national durable medical equipment
vendor to be eligible for preventive coverage.
Cervical Cancer Screening
>Pap smear: women age 21-65, every three years
>HPV/DNA test in combination with Pap smear:
women age 30-65, every five years
87624, 87625, 88141, 88142, 88143, 88147, 88148, 88150,
88152, 88153, 88164, 88165, 88166, 88167, 88174, 88175,
0500T
Select Designated Wellness Code from Code Group 1
G0101, G0123, G0124, G0141, G0143, G0144, G0145,
G0147, G0148, G0476, P3000, P3001, Q0091
Allowed with any diagnosis
Chlamydia Screening: all sexually active women
age 24 and younger, and older women at
increased risk
86631, 86632, 87110, 87270, 87320, 87490, 87491, 87492,
87810
Select Designated Wellness Code from Code Group 1
Cholesterol Screening: children/adolescents
>ages 9-11 years and 17-21 years
>ages 2-8 years and 12-16 years with risk factors
80061, 82465, 83718, 83719, 83721, 84478
Select Designated Wellness Code from Code Group 1
Cholesterol Screening: adults age 40-75
80061, 82465, 83718, 83719, 83721, 84478
Select Designated Wellness Code from Code Group 1
Colorectal Cancer Screening: beginning at age 50
by any of the following methods
>Fecal occult blood testing (FOBT)/fecal
immunochemical test (FIT) annually; or
>Sigmoidoscopy every five years; or
>Colonoscopy every 10 years; or
>Computed tomographic colonography (virtual
colonoscopy) every five years; or
>Double contrast barium enema (DCBE) every
five years
>Stool-based deoxyribonucleic acid (DNA) (i.e.,
Cologuard) every three years*
(*test frequency limitation imposed by the
manufacturer)
45330, 45331, 45338, 45346, 45378, 45380, 45381, 45384,
45385, 45388, 74270, 74280, 82270, 82274, 88305
Select Designated Wellness Code from Code Group 1
00812, 74263, 81528*, G0104, G0105, G0106, G0120,
G0121, G0122, G0328
Allowed with any diagnosis
(74263 MAY require precertification or other reasonable medical
management technique or practice depending on benefit plan design)
Colorectal Cancer Screening: consultation prior to
colonoscopy
S0285
Allowed with any diagnosis
Congenital Hypothyroidism Screening: newborns
84436, 84437, 84443
Select Designated Wellness Code from Code Group 1
Critical Congenital Heart Disease Screening:
newborns before discharge from hospital
Considered part of facility fee
Depression Screening/Maternal Depression
Screening: adolescents and adults including
pregnant and postpartum women
96161, G0444
Allowed with any diagnosis
Developmental/Behavioral Screening
G0451
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Select Designated Wellness Code from Code Group 1
96110, 96127, S0302
Allowed with any diagnosis
Fall Prevention: community dwelling adults age 65
years and older with risk factors
97110, 97112, 97113, 97116, 97150, 97161, 97162, 97163,
97164, 97530, G0159, S8990, S9131
Select Designated Wellness Code from Code Group 2
Age Limitation applied
Fluoride application: infants and children birth to
age 6 years (in primary care setting)
99188
Allowed with any diagnosis
Gestational Diabetes: pregnant women at first
prenatal visit for those at risk; all pregnant women
at 24 to 28 weeks gestation
82950, 82951, 82952
Allowed with a Maternity Diagnosis Code
Gonorrhea Screening: all sexually active women
age 24 and younger and older women at
increased risk
87590, 87591, 87850
Select Designated Wellness Code from Code Group 1; or
Allowed with a Maternity Diagnosis Code
Gonorrhea prophylactic ocular medication to
prevent blindness: newborns
No specific code; typically included on hospital billing
Hearing Screening: infants, children through age
10 years
Hearing Screening: adolescents age 11 years
through age 21 years (effective on or after
02/01/2018 as plans renew)
(not a complete hearing examination)
92550, 92552, 92553, 92558, 92567, 92568, 92579, 92582,
92583, 92585 92586, 92587, 92588
Select Designated Wellness Code from Code Group 1
92551, V5008
Allowed with any diagnosis
Age Limitations applied
Health Promotion/Prevention of Illness or Injury
Counseling
99401, 99402, 99403, 99404, 99411, 99412
Allowed with any diagnosis code
Hepatitis B Screening: pregnant women, first
prenatal visit; adolescents and adults at high risk
for infection
86704, 86705, 86706, 87340, 87341
Select Designated Wellness Code from Code Group 1; or
Allowed with a Maternity Diagnosis Code
G0499
Allowed with any diagnosis
Hepatitis C Screening: adults at risk for infection;
one-time screening for adults born between 1945
and 1965
86803, 87522
Select Designated Wellness Code from Code Group 1
G0472
Allowed with any diagnosis
High Blood Pressure Screening (Outside the
Clinical Setting): adults age 18 and older
93784, 93786, 93788, 93790, A4660*, A4663*, A4670*
Select Designated Wellness Code from Code Group 7
*Requires a prescription and must be ordered through
CareCentrix, Cigna's national durable medical equipment
vendor to be eligible for preventive coverage.
Human Immunodeficiency Virus (HIV) Infection
Screening: pregnant women, adolescents and
adults 15 to 65 years; younger adolescents or
86701,86703,87389, 87390, S3645
Select Designated Wellness Code from Code Group 1; or
Allowed with a Maternity Diagnosis Code
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Administrative Policy:
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adults with risk factors; annually for sexually active
women (adolescent and adult)
G0432, G0433, G0435,G0475
Allowed with any diagnosis
Lead Screening: children at risk for lead exposure
83655
Select Designated Wellness Code from Code Group 1
Lung Cancer Counseling to discuss need for
Screening
G0296
Allowed with any diagnosis
Lung Cancer Screening: annually for adults age
55 to 80 with 30 pack-year smoking history, and
currently smoke, or have quit within the past 15
years
71250
Select Designated Wellness Code from Code Group 3
(MAY require precertification or other reasonable medical management
technique or practice depending on benefit plan design)
G0297
Allowed with any diagnosis
(MAY require precertification or other reasonable medical management
technique or practice depending on benefit plan design)
Metabolic Screening: newborns (specific
combination of tests will vary according to state
law)
S3620
Allowed with any diagnosis
Nutrition/Physical Activity Counseling, Behavioral
Interventions: adults who are overweight or obese
and have risk factors for cardiovascular disease;
obese adults and children age six years and older
97802, 97803, 97804, S9470
Select Designated Wellness Code from Code Group 1
Subject to 3 visit limitation
G0446, G0447, G0473
Allowed with any diagnosis
Osteoporosis Screening: women age 65 or older
(or younger women with fracture risk as
determined by Fracture Risk Assessment Score)
76977, 77078, 77080, 77081, G0130
Select Designated Wellness Code from Code Group 1
(77078 MAY require precertification or other reasonable medical
management technique or practice depending on benefit plan design)
Phenylketonuria (PKU) Screening: newborns
84030
Select Designated Wellness Code from Code Group 1
Prostate Cancer Screening: men age 50 and older
or age 40 with risk factors
84152, 84153, 84154
Select Designated Wellness Code from Code Group 1
G0103
Allowed with any diagnosis
Rh incompatibility Screening: pregnant women at
first visit and repeat for unsensitized Rh negative
women at 24-28 weeks
86900, 86901
Allowed with a Maternity Diagnosis Code
Routine Immunizations
>Diphtheria, Tetanus Toxoids and Acellular
Pertussis (DTaP, Tdap, Td)
>Haemophilus influenza type b conjugate (Hib)
>Hepatitis A (Hep A)
>Hepatitis B (Hep B)
>Human Papillomavirus (HPV)
>Influenza
90460, 90461, 90471, 90472, 90473, 90474, 90620, 90621,
90630, 90632, 90633, 90634, 90636, 90644, 90647, 90648,
90649, 90650, 90651, 90653, 90654, 90655, 90656, 90657,
90658, 90661, 90662, 90670, 90673, 90674, 90680, 90681,
90682, 90685, 90686, 90687, 90688, 90696, 90698, 90700,
90702, 90707, 90710, 90713, 90714, 90715, 90716, 90723,
90732, 90733, 90734, 90736, 90739, 90740, 90743, 90744,
90746, 90747, 90748, 90750, 90756, G0008, G0009,G0010,
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>Measles, mumps and rubella (MMR)
>Meningococcal (MCV)
>Pneumococcal
>Poliovirus (IPV)
>Rotavirus (RV)
>Varicella
>Zoster
J3530 Q2034, Q2035, Q2036, Q2037, Q2038, Q2039,
S0195
Allowed with any diagnosis code
(90649, 90650, 90651 are subject to age limits depending on FDA licensed
indications)
Sexually Transmitted Infection (STI) Prevention
Counseling: sexually active women, annually;
sexually active adolescents; and men at increased
risk
G0445
Allowed with any diagnosis
Sickle Cell Disease Screening: newborns
85660
Select Designated Wellness Code from Code Group 1
Smoking and Tobacco Use Cessation
Counseling/Interventions: adults who smoke
99406, 99407
Allowed with any diagnosis code
Syphilis Screening: pregnant women and persons
at increased risk of infection
86592, 86593, 86780
Select Designated Wellness Code from Code Group 1; or
Allowed with a Maternity Diagnosis Code
Tuberculosis Screening: children, adolescents and
adults at increased risk
86480, 86481, 86580
Select Designated Wellness Code from Code Group 1
Venipuncture for Preventive Laboratory
Screenings
36415, 36416
Select Designated Wellness Code from Code Group 1; or
Allowed with a Maternity Diagnosis Code
Vision Screening: age 3 through age 15
(not a complete vision examination)
99173, 99174, 99177
Allowed with any diagnosis
Age Limitation applied
Women’s Contraceptive Services
Services for insertion/removal of intrauterine
devices, implants; fitting diaphragm or cervical cap
11976, 11981, 11982, 11983, 57170
58300, 58301, S4981
Allowed with any diagnosis code
Intrauterine devices (ParaGard®, Skyla®, Liletta™
Mirena®, Kyleena™)
J7300, J7301, J7296, J7297, J7298
Allowed with any diagnosis code
J3490 with NDC # 50419-424-01 (aka 50419042401) for
Kyleena (for service dates prior to 07-01-2017)
Select Designated Wellness Code from Code Group 6
Injection (Depot medroxyprogesterone acetate)
J1050, 96372
Select Designated Wellness Code from Code Group 4
Implants
J7307
Allowed with any diagnosis code
Surgical sterilization procedures for women
00851,58565, 58600, 58605, 58611, 58615, 58670, 58671,
A4264
Allowed with any diagnosis code
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Pathology service related to surgical sterilization
procedures for women
88302
Select Designated Wellness Code from Code Group 5
Follow-up confirmation procedure related to
surgical sterilization CPT 58565
58340, 74740, 76830
Select Designated Wellness Code from Code Group 5
Summary
Preventive care services are those screenings, tests, and services that are performed for symptom-free or
disease-free individuals. They may also include immunization and screening services for symptom-free or
disease-free individuals at increased risk for a particular disease.
ACA has designated specific resources for coverage by the Act: which include the evidenced-based items or services
that have in effect a rating of “A” or “B” in the current recommendations of the USPSTF; immunizations for routine use in
children, adolescents, and adults that have in effect a recommendation from the ACIP of the CDC; for infants, children,
and adolescents, the evidence-informed preventive care and screenings provided for in the comprehensive guidelines
supported by the HRSA; and with respect to women, evidence-informed preventive care and screening provided for in
comprehensive guidelines supported by HRSA. If a recommendation or guideline does not specify the frequency,
method, treatment, or setting for the provision of that service, reasonable medical management techniques may be
used to determine any coverage limitations.
Professional society statements and guidelines may vary and are not
considered part of ACA sources.
Coding/Billing Information
Note: 1) This list of codes may not be all-inclusive.
2) Deleted codes and codes which are not effective at the time the service is rendered may not be eligible
for reimbursement.
Wellness Examinations
Covered when medically necessary when used to report wellness examinations, well-woman
examinations or women’s services related to contraception management:
CPT
®
*
Codes
Description
99381
Initial comprehensive preventive medicine evaluation and management of an
individual including an age and gender appropriate history, examination,
counseling/anticipatory guidance/risk factor reduction interventions, and the
ordering of laboratory/diagnostic procedures, new patient; infant (age younger
than 1 year)
99382
Initial comprehensive preventive medicine evaluation and management of an
individual including an age and gender appropriate history, examination,
counseling/anticipatory guidance/risk factor reduction interventions, and the
ordering of laboratory/diagnostic procedures, new patient; early childhood (age 1
through 4 years)
99383
Initial comprehensive preventive medicine evaluation and management of an
individual including an age and gender appropriate history, examination,
counseling/anticipatory guidance/risk factor reduction interventions, and the
ordering of laboratory/diagnostic procedures, new patient; late childhood (age 5
through 11 years)
99384
Initial comprehensive preventive medicine evaluation and management of an
individual including an age and gender appropriate history, examination,
counseling/anticipatory guidance/risk factor reduction interventions, and the
ordering of laboratory/diagnostic procedures, new patient; adolescent (age 12
through 17 years)
99385
Initial comprehensive preventive medicine evaluation and management of an
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Administrative Policy:
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individual including an age and gender appropriate history, examination,
counseling/anticipatory guidance/risk factor reduction interventions, and the
ordering of laboratory/diagnostic procedures, new patient; 18-39 years
99386
Initial comprehensive preventive medicine evaluation and management of an
individual including an age and gender appropriate history, examination,
counseling/anticipatory guidance/risk factor reduction interventions, and the
ordering of laboratory/diagnostic procedures, new patient; 40-64 years
99387
Initial comprehensive preventive medicine evaluation and management of an
individual including an age and gender appropriate history, examination,
counseling/anticipatory guidance/risk factor reduction interventions, and the
ordering of laboratory/diagnostic procedures, new patient; 65 years and older
99391
Periodic comprehensive preventive medicine reevaluation and management of
an individual including an age and gender appropriate history, examination,
counseling/anticipatory guidance/risk factor reduction interventions, and the
ordering of laboratory/diagnostic procedures, established patient; infant (age
younger than 1 year)
99392
Periodic comprehensive preventive medicine reevaluation and management of
an individual including an age and gender appropriate history, examination,
counseling/anticipatory guidance/risk factor reduction interventions, and the
ordering of laboratory/diagnostic procedures, established patient; early childhood
(age 1 through 4 years)
99393
Periodic comprehensive preventive medicine reevaluation and management of
an individual including an age and gender appropriate history, examination,
counseling/anticipatory guidance/risk factor reduction interventions, and the
ordering of laboratory/diagnostic procedures, established patient; late childhood
(age 5 through 11 years)
99394
Periodic comprehensive preventive medicine reevaluation and management of
an individual including an age and gender appropriate history, examination,
counseling/anticipatory guidance/risk factor reduction interventions, and the
ordering of laboratory/diagnostic procedures, established patient; adolescent
(age 12 through 17 years)
99395
Periodic comprehensive preventive medicine reevaluation and management of
an individual including an age and gender appropriate history, examination,
counseling/anticipatory guidance/risk factor reduction interventions, and the
ordering of laboratory/diagnostic procedures, established patient; 18-39 years
99396
Periodic comprehensive preventive medicine reevaluation and management of
an individual including an age and gender appropriate history, examination,
counseling/anticipatory guidance/risk factor reduction interventions, and the
ordering of laboratory/diagnostic procedures, established patient; 40-64 years
99397
Periodic comprehensive preventive medicine reevaluation and management of
an individual including an age and gender appropriate history, examination,
counseling/anticipatory guidance/risk factor reduction interventions, and the
ordering of laboratory/diagnostic procedures, established patient; 65 years and
older
99461
Initial care, per day, for evaluation and management of normal newborn infant
seen in other than hospital or birthing center
HCPCS
Codes
Description
G0402
Initial preventive physical examination; face-to-face visit, services limited to new
beneficiary during the first 12 months of Medicare enrollment
G0438
Annual wellness visit; includes a personalized prevention plan of service (PPS),
initial visit
G0439
Annual wellness visit, includes a personalized prevention plan of service (PPS),
subsequent visit
S0610
Annual gynecological examination, new patient
S0612
Annual gynecological examination, established patient
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S0613
Annual gynecological examination; clinical breast examination without pelvic
evaluation
Preventive Care Screenings and Interventions
Covered when medically necessary when used to report preventive care screenings and interventions,
are not for treatment of illness or injury, and when billed with a designated wellness diagnosis code:
CPT
®
*
Codes
Description
00810
Anesthesia for lower intestinal endoscopic procedures, endoscope introduced
distal to duodenum (Deleted code effective 01-01-2018)
00812
Anesthesia for lower intestinal endoscopic procedures, endoscope introduced
distal to duodenum; screening colonoscopy (New code effective 01-01-2018)
00851
Anesthesia for intraperitoneal procedures in lower abdomen including
laparoscopy; tubal ligation/transection
0403T
Preventive behavior change, intensive program of prevention of diabetes using a
standardized diabetes prevention program curriculum, provided to individuals in
a group setting, minimum 60 minutes, per day
0488T
Preventive behavior change, online/electronic structured intensive program for
prevention of diabetes using a standardized diabetes prevention program
curriculum, provided to an individual, per 30 days (New code effective 01-01-
2018)
0500T
Infectious agent detection by nucleic acid (DNA or RNA), human papillomavirus
(HPV) for five or more separately reported high-risk HPV types (eg, 16, 18, 31,
33, 35, 39, 45, 51, 52, 56, 58, 59, 68) (ie, genotyping) (New code effective 01-
01-2018)
11976
Removal, implantable contraceptive capsules
11981
Insertion, non-biodegradable drug delivery implant
11982
Removal, non-biodegradable drug delivery implant
11983
Removal with insertion, non-biodegradable drug delivery implant
36415
Collection of venous blood by venipuncture
36416
Collection of capillary blood specimen (e.g., finger, heel, ear stick)
45330
Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by
brushing or washing, when performed (separate procedure)
45331
Sigmoidoscopy, flexible; with biopsy, single or multiple
45338
Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by
snare technique
45346
Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s)
(includes pre- and post-dilation and guide wire passage, when performed)
45378
Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing
or washing, when performed (separate procedure)
45380
Colonoscopy, flexible; with biopsy, single or multiple
45381
Colonoscopy, flexible; with directed submucosal injection(s), any substance
45384
Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by
hot biopsy forceps
45385
Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by
snare technique
45388
Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s)
(includes pre- and post-dilation and guide wire passage, when performed)
57170
Diaphragm or cervical cap fitting with instructions
58300
Insertion of intrauterine device (IUD)
58301
Removal of intrauterine device (IUD)
58340
Catheterization and introduction of saline or contrast material for saline infusion
sonohysterography (SIS) or hysterosalpingography
58565
Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce
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occlusion by placement of permanent implants
58600
Ligation or transection of fallopian tube(s), abdominal or vaginal approach,
unilateral or bilateral
58605
Ligation or transection of fallopian tube(s), abdominal or vaginal approach,
postpartum, unilateral or bilateral, during same hospitalization (separate
procedure)
58611
Ligation or transection of fallopian tube(s) when done at the time of cesarean
delivery or intra-abdominal surgery (not a separate procedure) (List separately in
addition to code for primary procedure)
58615
Occlusion of fallopian tube(s) by device (eg, band, clip, Falope ring) vaginal or
suprapubic approach
58670
Laparoscopy, surgical; with fulguration of oviducts (with or without transection)
58671
Laparoscopy, surgical; with occlusion of oviducts by device (eg, band, clip, or
Falope ring)
71250
Computed tomography, thorax; without contrast material
74263
Computed tomographic (CT) colonography, screening, including image
postprocessing
74270
Radiologic examination, colon; contrast (eg, barium) enema, with or without KUB
74280
Radiologic examination, colon; air contrast with specific high density barium, with
or without glucagon
74740
Hysterosalpingography, radiological supervision and interpretation
76700
Ultrasound, abdominal, real time with image documentation; complete
76705
Ultrasound, abdominal, real time with image documentation; limited (eg, single
organ, quadrant, follow-up)
76706
Ultrasound, abdominal aorta, real time with image documentation, screening
study for abdominal aortic aneurysm (AAA)
76770
Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image
documentation; complete
76775
Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image
documentation; limited
76830
Ultrasound, transvaginal
76977
Ultrasound bone density measurement and interpretation, peripheral site(s), any
method
77063
Screening digital breast tomosynthesis, bilateral (List separately in addition to
code for primary procedure)
77065
Diagnostic mammography, including computer-aided detection (CAD) when
performed; unilateral
77066
Diagnostic mammography, including computer-aided detection (CAD) when
performed; bilateral
77067
Screening mammography, bilateral (2-view study of each breast), including
computer-aided detection (CAD) when performed
77078
Computed tomography, bone mineral density study, 1 or more sites; axial
skeleton (eg, hips, pelvis, spine)
77080
Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites;
axial skeleton (eg, hips, pelvis, spine)
77081
Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites;
appendicular skeleton (peripheral) (eg, radius, wrist, heel)
80061
Lipid panel This panel must include the following: Cholesterol, serum, total
(82465) Lipoprotein, direct measurement, high density cholesterol (HDL
cholesterol) (83718) Triglycerides (84478)
81162
BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and ovarian
cancer) gene analysis; full sequence analysis and full duplication/deletion
analysis
81211
BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and ovarian
cancer) gene analysis; full sequence analysis and common duplication/deletion
variants in BRCA1 (ie, exon 13 del 3.835kb, exon 13 dup 6kb, exon 14-20 del
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26kb, exon 22 del 510bp, exon 8-9 del 7.1kb)
81212
BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and ovarian
cancer) gene analysis; 185delAG, 5385insC, 6174delT variants
81213
BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and ovarian
cancer) gene analysis; uncommon duplication/deletion variants
81214
BRCA1 (breast cancer 1) (eg, hereditary breast and ovarian cancer) gene
analysis; full sequence analysis and common duplication/deletion variants (ie,
exon 13 del 3.835kb, exon 13 dup 6kb, exon 14-20 del 26kb, exon 22 del 510bp,
exon 8-9 del 7.1kb)
81215
BRCA1 (breast cancer 1) (eg, hereditary breast and ovarian cancer) gene
analysis; known familial variant
81216
BRCA2 (breast cancer 2) (eg, hereditary breast and ovarian cancer) gene
analysis; full sequence analysis
81217
BRCA2 (breast cancer 2) (eg, hereditary breast and ovarian cancer) gene
analysis; known familial variant
81528
Oncology (colorectal) screening, quantitative real-time target and signal
amplification of 10 DNA markers (KRAS mutations, promoter methylation of
NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a
positive or negative result
82247
Bilirubin, total
82270
Blood, occult, by peroxidase activity (eg, guaiac), qualitative; feces, consecutive
collected specimens with single determination, for colorectal neoplasm screening
(ie, patient was provided 3 cards or single triple card for consecutive collection)
82274
Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative,
feces, 1-3 simultaneous determinations
82465
Cholesterol, serum or whole blood, total
82947
Glucose; quantitative, blood (except reagent strip)
82948
Glucose; blood, reagent strip
82950
Glucose; post glucose dose (includes glucose)
82951
Glucose; tolerance test (GTT), 3 specimens (includes glucose)
82952
Glucose; tolerance test, each additional beyond 3 specimens (List separately in
addition to code for primary procedure)
83036
Hemoglobin; glycosylated (A1C)
83655
Lead
83718
Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol)
83719
Lipoprotein, direct measurement; VLDL cholesterol
83721
Lipoprotein, direct measurement; LDL cholesterol
84030
Phenylalanine (PKU), blood
84152
Prostate specific antigen (PSA); complexed (direct measurement)
84153
Prostate specific antigen (PSA); total
84154
Prostate specific antigen (PSA); free
84436
Thyroxine; total
84437
Thyroxine; requiring elution (eg, neonatal)
84443
Thyroid stimulating hormone (TSH)
84478
Triglycerides
85013
Blood count; spun microhematocrit
85014
Blood count; hematocrit (Hct)
85018
Blood count; hemoglobin (Hgb)
85025
Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet
count) and automated differential WBC count
85027
Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet
count)
85041
Blood count; red blood cell (RBC), automated
85660
Sickling of RBC, reduction
86480
Tuberculosis test, cell mediated immunity antigen response measurement;
gamma interferon
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86481
Tuberculosis test, cell mediated immunity antigen response measurement;
enumeration of gamma interferon-producing T-cells in cell suspension
86580
Skin test; tuberculosis, intradermal
86592
Syphilis test, non-treponemal antibody; qualitative (eg, VDRL, RPR, ART)
86593
Syphilis test, non-treponemal antibody; quantitative
86631
Antibody; Chlamydia
86632
Antibody; Chlamydia, IgM
86701
Antibody; HIV-1
86703
Antibody; HIV-1 and HIV-2, single result
86704
Hepatitis B core antibody (HBcAb); total
86705
Hepatitis B core antibody (HBcAb); IgM antibody
86706
Hepatitis B surface antibody (HBsAb)
86780
Antibody; Treponema pallidum
86803
Hepatitis C antibody;
86900
Blood typing, serologic; ABO
86901
Blood typing, serologic; Rh (D)
87086
Culture, bacterial; quantitative colony count, urine
87088
Culture, bacterial; with isolation and presumptive identification of each isolate,
urine
87110
Culture, chlamydia, any source
87270
Infectious agent antigen detection by immunofluorescent technique; Chlamydia
trachomatis
87320
Infectious agent antigen detection by enzyme immunoassay technique,
qualitative or semiquantitative, multiple-step method; Chlamydia trachomatis
87340
Infectious agent antigen detection by enzyme immunoassay technique,
qualitative or semiquantitative, multiple-step method; hepatitis B surface antigen
(HBsAg)
87341
Infectious agent antigen detection by enzyme immunoassay technique,
qualitative or semiquantitative, multiple-step method; hepatitis B surface antigen
(HBsAg) neutralization
87389
Infectious agent antigen detection by enzyme immunoassay technique,
qualitative or semiquantitative, multiple-step method; HIV-1 antigen(s), with HIV-
1 and HIV-2 antibodies, single result
87390
Infectious agent antigen detection by enzyme immunoassay technique,
qualitative or semiquantitative, multiple-step method; HIV-1
87490
Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia
trachomatis, direct probe technique
87491
Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia
trachomatis, amplified probe technique
87492
Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia
trachomatis, quantification
87522
Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C,
quantification, includes reverse transcription when performed
87590
Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae,
direct probe technique
87591
Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae,
amplified probe technique
87624
Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus
(HPV), high-risk types (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68)
87625
Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus
(HPV), types 16 and 18 only, includes type 45, if performed
87810
Infectious agent antigen detection by immunoassay with direct optical
observation; Chlamydia trachomatis
87850
Infectious agent antigen detection by immunoassay with direct optical
observation; Neisseria gonorrhoeae
88141
Cytopathology, cervical or vaginal (any reporting system), requiring interpretation
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A004
by physician
88142
Cytopathology, cervical or vaginal (any reporting system), collected in
preservative fluid, automated thin layer preparation; manual screening under
physician supervision
88143
Cytopathology, cervical or vaginal (any reporting system), collected in
preservative fluid, automated thin layer preparation; with manual screening and
rescreening under physician supervision
88147
Cytopathology smears, cervical or vaginal; screening by automated system
under physician supervision
88148
Cytopathology smears, cervical or vaginal; screening by automated system with
manual rescreening under physician supervision
88150
Cytopathology, slides, cervical or vaginal; manual screening under physician
supervision
88152
Cytopathology, slides, cervical or vaginal; with manual screening and computer-
assisted rescreening under physician supervision
88153
Cytopathology, slides, cervical or vaginal; with manual screening and
rescreening under physician supervision
88154
Cytopathology, slides, cervical or vaginal; with manual screening and computer-
assisted rescreening using cell selection and review under physician supervision
(Deleted code effective 01-01-2018)
88164
Cytopathology, slides, cervical or vaginal (the Bethesda System); manual
screening under physician supervision
88165
Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual
screening and rescreening under physician supervision
88166
Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual
screening and computer-assisted rescreening under physician supervision
88167
Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual
screening and computer-assisted rescreening using cell selection and review
under physician supervision
88174
Cytopathology, cervical or vaginal (any reporting system), collected in
preservative fluid, automated thin layer preparation; screening by automated
system, under physician supervision
88175
Cytopathology, cervical or vaginal (any reporting system), collected in
preservative fluid, automated thin layer preparation; with screening by automated
system and manual rescreening or review, under physician supervision
88720
Bilirubin, transcutaneous
88302
Level II - Surgical pathology, gross and microscopic examination
88305
Level IV - Surgical pathology, gross and microscopic
90460
Immunization administration through 18 years of age via any route of
administration, with counseling by physician or other qualified health care
professional; first or only component of each vaccine or toxoid administered
90461
Immunization administration through 18 years of age via any route of
administration, with counseling by physician or other qualified health care
professional; each additional vaccine or toxoid component administered (List
separately in addition to code for primary procedure)
90471
Immunization administration (includes percutaneous, intradermal, subcutaneous,
or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)
90472
Immunization administration (includes percutaneous, intradermal, subcutaneous,
or intramuscular injections); each additional vaccine (single or combination
vaccine/toxoid) (List separately in addition to code for primary procedure)
90473
Immunization administration by intranasal or oral route; 1 vaccine (single or
combination vaccine/toxoid)
90474
Immunization administration by intranasal or oral route; each additional vaccine
(single or combination vaccine/toxoid) (List separately in addition to code for
primary procedure)
90620
Meningococcal recombinant protein and outer membrane vesicle vaccine,
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serogroup B (MenB-4C), 2 dose schedule, for intramuscular use
90621
Meningococcal recombinant lipoprotein vaccine, serogroup B (MenB-FHbp), 2 or
3 dose schedule, for intramuscular use
90630
Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, for
intradermal use
90632
Hepatitis A vaccine (HepA), adult dosage, for intramuscular use
90633
Hepatitis A vaccine (HepA), pediatric/adolescent dosage-2 dose schedule, for
intramuscular use
90634
Hepatitis A vaccine (HepA), pediatric/adolescent dosage-3 dose schedule, for
intramuscular use
90636
Hepatitis A and hepatitis B vaccine (HepA-HepB), adult dosage, for
intramuscular use
90644
Meningococcal conjugate vaccine, serogroups C & Y and Haemophilus
influenzae type b vaccine (Hib-MenCY), 4 dose schedule, when administered to
children 6 weeks-18 months of age, for intramuscular use
90647
Haemophilus influenzae type b vaccine (Hib), PRP-OMP conjugate, 3 dose
schedule, for intramuscular use
90648
Haemophilus influenzae type b vaccine (Hib), PRP-T conjugate, 4 dose
schedule, for intramuscular use
90649
†
Human Papillomavirus vaccine, types 6, 11, 16, 18, quadrivalent (4vHPV), 3
dose schedule, for intramuscular use
90650
†
Human Papillomavirus vaccine, types 16, 18, bivalent (2vHPV), 3 dose
schedule, for intramuscular use
90651
†
Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58,
nonavalent (9vHPV), 2 or 3 dose schedule, for intramuscular use
90653
Influenza vaccine, inactivated (IIV), subunit, adjuvanted, for intramuscular use
90654
Influenza virus vaccine, trivalent (IIV3), split virus, preservative-free, for
intradermal use
90655
Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.25 mL
dosage, for intramuscular use
90656
Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.5mL
dosage, for intramuscular use
90657
Influenza virus vaccine, trivalent (IIV3), split virus, 0.25 mL dosage, for
intramuscular use
90658
Influenza virus vaccine, trivalent (IIV3), split virus, 0.5 mL dosage, for
intramuscular use
90660
Influenza virus vaccine, trivalent, live (LAIV3), for intranasal use (Effective for
Dates of Service on or after 07/01/2018)
90661
Influenza virus vaccine, trivalent (ccIIV3), derived from cell cultures, subunit,
preservative and antibiotic free, 0.5 mL dosage, for intramuscular use
90662
Influenza virus vaccine (IIV), split virus, preservative free, enhanced
immunogenicity via increased antigen content, for intramuscular use
90670
Pneumococcal conjugate vaccine, 13 valent (PCV13), for intramuscular use
90672
Influenza virus vaccine, quadrivalent, live (LAIV4), for intranasal use (Effective
for Dates of Service on or after 07/01/2018)
90673
Influenza virus vaccine, trivalent (RIV3), derived from recombinant DNA,
hemagglutinin (HA) protein only, preservative and antibiotic free, for
intramuscular use
90674
Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit,
preservative and antibiotic free, 0.5 mL dosage, for intramuscular use
90680
Rotavirus vaccine, pentavalent (RV5), 3 dose schedule, live, for oral use
90681
Rotavirus vaccine, human, attenuated (RV1), 2 dose schedule, live, for oral use
90682
Influenza virus vaccine, quadrivalent (RIV4), derived from recombinant DNA,
hemagglutinin (HA) protein only, preservative and antibiotic free, for
intramuscular use
90685
Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.25 mL
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dosage, for intramuscular use
90686
Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0,5 mL
dosage, for intramuscular use
90687
Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.25 mL dosage, for
intramuscular use
90688
Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.5 mL dosage, for
intramuscular use
90696
Diphtheria, tetanus toxoids, acellular pertussis vaccine and inactivated poliovirus
vaccine (DTaP-IPV), when administered to children 4 through 6 years of age, for
intramuscular use
90698
Diphtheria, tetanus toxoids, acellular pertussis vaccine, Haemophilus influenzae
type b, and inactivated poliovirus vaccine (DTaP-IPV/Hib), for intramuscular use
90700
Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), when
administered to individuals younger than 7 years, for intramuscular use
90702
Diphtheria and tetanus toxoids adsorbed (DT) when administered to individuals
younger than 7 years, for intramuscular use
90707
Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use
90710
Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous
use
90713
Poliovirus vaccine, inactivated (IPV), for subcutaneous or intramuscular use
90714
Tetanus and diphtheria toxoids adsorbed (Td), preservative free, when
administered to individuals 7 years or older, for intramuscular use
90715
Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when
administered to individuals 7 years or older, for intramuscular use
90716
Varicella virus vaccine (VAR), live, for subcutaneous use
90723
Diphtheria, tetanus toxoids, acellular pertussis vaccine, hepatitis B, and
inactivated poliovirus vaccine (DTaP-HepB-IPV), for intramuscular use
90732
Pneumococcal polysaccharide vaccine, 23-valent (PPSV23), adult or
immunosuppressed patient dosage, when administered to individuals 2 years or
older, for subcutaneous or intramuscular use
90733
Meningococcal polysaccharide vaccine, serogroups A, C, Y, W-135, quadrivalent
(MPSV4), for subcutaneous use
90734
Meningococcal conjugate vaccine, serogroups A, C, Y and W-135, quadrivalent
(MCV4 or MenACWY), for intramuscular use
90736
Zoster (shingles) vaccine (HZV), live, for subcutaneous injection
90739
Hepatitis B vaccine (HepB), adult dosage, 2 dose schedule, for intramuscular
use
90740
Hepatitis B vaccine (HepB), dialysis or immunosuppressed patient dosage, 3
dose schedule, for intramuscular use
90743
Hepatitis B vaccine (HepB), adolescent, 2 dose schedule, for intramuscular use
90744
Hepatitis B vaccine (HepB), pediatric/adolescent dosage, 3 dose schedule, for
intramuscular use
90746
Hepatitis B vaccine (HepB), adult dosage, 3 dose schedule, for intramuscular
use
90747
Hepatitis B vaccine (HepB), dialysis or immunosuppressed patient dosage, 4
dose schedule, for intramuscular use
90748
Hepatitis B and Haemophilus influenzae type b vaccine (Hib-HepB), for
intramuscular use
90750
Zoster (shingles) vaccine (HZV), recombinant, sub-unit, adjuvanted, for
intramuscular injection
90756
Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit,
antibiotic free, 0.5mL dosage, for intramuscular use
92550
Tympanometry and reflex threshold measurements
92551
Screening test, pure tone, air only
92552
Pure tone audiometry (threshold); air only
92553
Pure tone audiometry (threshold); air and bone
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92558
Evoked otoacoustic emissions, screening (qualitative measurement of distortion
product or transient evoked otoacoustic emissions), automated analysis
92567
Tympanometry (impedance testing)
92568
Acoustic reflex testing, threshold
92579
Visual reinforcement audiometry (VRA)
92582
Conditioning play audiometry
92583
Select picture audiometry
92585
Auditory evoked potentials for evoked response audiometry and/or testing of the
central nervous system; comprehensive
92586
Auditory evoked potentials for evoked response audiometry and/or testing of the
central nervous system; limited
92587
Distortion product evoked otoacoustic emissions; limited evaluation (to confirm
the presence or absence of hearing disorder, 3-6 frequencies) or transient
evoked otoacoustic emissions, with interpretation and report
92588
Distortion product evoked otoacoustic emissions; comprehensive diagnostic
evaluation (quantitative analysis of outer hair cell function by cochlear mapping,
minimum of 12 frequencies), with interpretation and report
93784
Ambulatory blood pressure monitoring, utilizing a system such as magnetic tape
and/or computer disk, for 24 hours or longer; including recording, scanning
analysis, interpretation and report
93786
Ambulatory blood pressure monitoring, utilizing a system such as magnetic tape
and/or computer disk, for 24 hours or longer; recording only
93788
Ambulatory blood pressure monitoring, utilizing a system such as magnetic tape
and/or computer disk, for 24 hours or longer; scanning analysis with report
93790
Ambulatory blood pressure monitoring, utilizing a system such as magnetic tape
and/or computer disk, for 24 hours or longer; review with interpretation and
report
96040
Medical genetics and genetic counseling services, each 30 minutes face-to-face
with patient/family
96110
Developmental screening (eg, developmental milestone survey, speech and
language delay screen), with scoring and documentation, per standardized
instrument
96127
Brief emotional/behavioral assessment (eg, depression inventory, attention-
deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per
standardized instrument
96160
Administration of patient-focused health risk assessment instrument (eg, health
hazard appraisal) with scoring and documentation, per standardized instrument
96161
Administration of caregiver-focused health risk assessment instrument (e.g.,
depression inventory) for the benefit of the patient, with scoring and
documentation, per standardized instrument)
96372
Therapeutic, prophylactic, or diagnostic injection (specify substance or drug);
subcutaneous or intramuscular
97110
Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises
to develop strength and endurance, range of motion and flexibility
97112
Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular
reeducation of movement, balance, coordination, kinesthetic sense, posture,
and/or proprioception for sitting and/or standing activities
97113
Therapeutic procedure, 1 or more areas, each 15 minutes; aquatic therapy with
therapeutic exercises
97116
Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes
stair climbing)
97150
Therapeutic procedure(s), group (2 or more individuals)
97161
Physical therapy evaluation; low complexity, requiring these components: A
history with no personal factors and/or comorbidities that impact the plan of care;
An examination of body system(s) using standardized tests and measures
addressing 1-2 elements from any of the following: body structures and
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functions, activity limitations, and/or participation restrictions; A clinical
presentation with stable and/or uncomplicated characteristics; and Clinical
decision making of low complexity using standardized patient assessment
instrument and/or measureable assessment of functional outcome. Typically, 20
minutes are spent face-to-face with the patient and/or family.
97162
Physical therapy evaluation: moderate complexity, requiring these components:
A history of present problem with 1-2 personal factors and/or comorbidities that
impact the plan of care; An examination of body systems using standardized
tests and measures in addressing a total of 3 or more elements from any of the
following: body structures and functions, activity limitations, and/or participation
restrictions; An evolving clinical presentation with changing characteristics; and
Clinical decision making of moderate complexity using standardized patient
assessment instrument and/or measurable assessment of functional outcome.
Typically, 30 minutes are spent face-to-face with the patient and/or family
97163
Physical therapy evaluation: high complexity, requiring these components: A
history of present problem with 3 or more personal factors and/or comorbidities
that impact the plan of care; An examination of body systems using standardized
tests and measures addressing a total of 4 or more elements from any of the
following: body structures and functions, activity limitations, and/or participation
restrictions; A clinical presentation with unstable and unpredictable
characteristics; and Clinical decision making of high complexity using
standardized patient assessment instrument and/or measureable assessment of
functional outcome. Typically, 45 minutes are spent face-to-face with the patient
and/or family.
97164
Re-evaluation of physical therapy established plan of care, requiring these
components: An examination including a review of history and use of
standardized tests and measures is required; and Revised plan of care using a
standardized patient assessment instrument and/or measurable assessment of
functional outcome. Typically, 20 minutes are spent face-to-face with the patient
and/or family.
97530
Therapeutic activities, direct (one-on-one) patient contact (use of dynamic
activities to improve functional performance), each 15 minutes
97802
Medical nutrition therapy; initial assessment and intervention, individual, face-to-
face with the patient, each 15 minutes
97803
Medical nutrition therapy; re-assessment and intervention, individual, face-to-
face with the patient, each 15 minutes
97804
Medical nutrition therapy; group (2 or more individual(s)), each 30 minutes
99173
Screening test of visual acuity, quantitative, bilateral
99174
Instrument-based ocular screening (eg, photoscreening, automated-refraction),
bilateral; with remote analysis and report
99177
Instrument-based ocular screening (eg, photoscreening, automated-refraction),
bilateral; with on-site analysis
99188
Application of topical fluoride varnish by a physician or other qualified health care
professional
99401
Preventive medicine counseling and/or risk factor reduction intervention(s)
provided to an individual (separate procedure); approximately 15 minutes
99402
Preventive medicine counseling and/or risk factor reduction intervention(s)
provided to an individual (separate procedure); approximately 30 minutes
99403
Preventive medicine counseling and/or risk factor reduction intervention(s)
provided to an individual (separate procedure); approximately 45 minutes
99404
Preventive medicine counseling and/or risk factor reduction intervention(s)
provided to an individual (separate procedure); approximately 60 minutes
99406
Smoking and tobacco use cessation counseling visit; intermediate, greater than
3 minutes up to 10 minutes
99407
Smoking and tobacco use cessation counseling visit; intensive, greater than 10
minutes
99408
Alcohol and/or substance (other than tobacco) abuse structured screening (eg,
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AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes
99409
Alcohol and/or substance (other than tobacco) abuse structured screening (eg,
AUDIT, DAST), and brief intervention (SBI) services; greater than 30 minutes
99411
Preventive medicine counseling and/or risk factor reduction intervention(s)
provided to individuals in a group setting (separate procedure); approximately 30
minutes
99412
Preventive medicine counseling and/or risk factor reduction intervention(s)
provided to individuals in a group setting (separate procedure); approximately 60
minutes
†
Note: Subject to age limits depending on FDA licensed indications
HCPCS
Codes
Description
A4264
Permanent implantable contraceptive intratubal occlusion device(s) and delivery
system
A4281
Tubing for breast pump, replacement
A4282
Adapter for breast pump, replacement
A4283
Cap for breast pump bottle, replacement
A4284
Breast shield and splash protector for use with breast pump, replacement
A4285
Polycarbonate bottle for use with breast pump, replacement
A4286
Locking ring for breast pump, replacement
A4660
Sphygmomanometer/blood pressure apparatus with cuff and stethoscope
A4663
Blood pressure cuff only
A4670
Automatic blood pressure monitor
E0602
Breast pump, manual, any type
E0603
Breast pump, electric (AC and/or DC), any type
E0604
Breast pump, hospital grade, electric (AC and/or DC), any type
G0008
Administration of influenza virus vaccine
G0009
Administration of pneumococcal vaccine
G0010
Administration of hepatitis B vaccine
G0101
Cervical or vaginal cancer screening; pelvic and clinical breast examination
G0103
Prostate cancer screening; prostate specific antigen test (PSA)
G0104
Colorectal cancer screening; flexible sigmoidoscopy
G0105
Colorectal cancer screening; colonoscopy on individual at high risk
G0106
Colorectal cancer screening; alternative to G0104, screening sigmoidoscopy,
barium enema
G0120
Colorectal cancer screening; alternative to G0105, screening colonoscopy,
barium enema
G0121
Colorectal cancer screening; colonoscopy on individual not meeting criteria for
high risk
G0122
Colorectal cancer screening; barium enema
G0123
Screening cytopathology, cervical or vaginal (any reporting system), collected in
preservative fluid, automated thin layer preparation, screening by
cytotechnologist under physician supervision
G0124
Screening cytopathology, cervical or vaginal (any reporting system), collected in
preservative fluid, automated thin layer preparation, requiring interpretation by
physician
G0130
Single energy x-ray absorptiometry (SEXA) bone density study, one or more
sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel)
G0141
Screening cytopathology smears, cervical or vaginal, performed by automated
system, with manual rescreening, requiring interpretation by physician
G0143
Screening cytopathology, cervical or vaginal (any reporting system), collected in
preservative fluid, automated thin layer preparation, with manual screening and
rescreening by cytotechnologist under physician supervision
G0144
Screening cytopathology, cervical or vaginal (any reporting system), collected in
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preservative fluid, automated thin layer preparation, with screening by automated
system, under physician supervision
G0145
Screening cytopathology, cervical or vaginal (any reporting system), collected in
preservative fluid, automated thin layer preparation, with screening by automated
system and manual rescreening under physician supervision
G0147
Screening cytopathology smears, cervical or vaginal, performed by automated
system under physician supervision
G0148
Screening cytopathology smears, cervical or vaginal, performed by automated
system with manual rescreening
G0159
Services performed by a qualified physical therapist, in the home health setting,
in the establishment or delivery of a safe and effective physical therapy
maintenance program, each 15 minutes
G0202
Screening mammography, bilateral (2-view study of each breast), including
computer-aided detection (CAD) when performed (Code deleted effective 01-01-
2018)
G0204
Diagnostic mammography, including computer-aided detection (CAD) when
performed; bilateral (Code deleted effective 01-01-2018)
G0206
Diagnostic mammography, including computer-aided detection (CAD) when
performed; unilateral (Code deleted effective 01-01-2018)
G0296
Counseling visit to discuss need for lung cancer screening using low dose CT
scan (LDCT) (service is for eligibility determination and shared decision making)
G0297
Low dose CT scan (LDCT) for lung cancer screening
G0306
Complete CBC, automated (HgB, HCT, RBC, WBC, without platelet count) and
automated WBC differential count
G0307
Complete (CBC), automated (HgB, Hct, RBC, WBC; without platelet count)
G0328
Colorectal cancer screening; fecal occult blood test, immunoassay, 1-3
simultaneous determinations
G0389
Ultrasound B-scan and/or real time with image documentation; for abdominal
aortic aneurysm (AAA) screening
G0396
Alcohol and/or substance (other than tobacco) abuse structured assessment
(e.g., AUDIT, DAST), and brief intervention 15 to 30 minutes
G0397
Alcohol and/or substance (other than tobacco) abuse structured assessment
(e.g., AUDIT, DAST), and intervention, greater than 30 minutes
G0432
Infectious agent antibody detection by enzyme immunoassay (EIA) technique,
HIV-1 and/or HIV-2, screening
G0433
Infectious agent antibody detection by enzyme-linked immunosorbent assay
(ELISA) technique, HIV-1 and/or HIV-2, screening
G0435
Infectious agent antigen detection by rapid antibody test of oral mucosa
transudate, HIV-1 or HIV-2, screening
G0436
Smoking and tobacco cessation counseling visit for the asymptomatic patient;
intermediate, greater than 3 minutes, up to 10 minutes (Code deleted
09/30/2016)
G0437
Smoking and tobacco cessation counseling visit for the asymptomatic patient;
intermediate, greater than 10 minutes (Code deleted 09/30/2016)
G0442
Annual alcohol misuse screening, 15 minutes
G0443
Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes
G0444
Annual depression screening, 15 minutes
G0445
Semiannual high intensity behavioral counseling to prevent STIs, individual,
face-to-face, includes education skills training & guidance on how to change
sexual behavior
G0446
Annual, face-to-face intensive behavioral therapy for cardiovascular disease,
individual, 15 minutes
G0447
Face-to-face behavioral counseling for obesity, 15 minutes
G0451
Development testing, with interpretation and report, per standardized instrument
form
G0472
Hepatitis C antibody screening for individual at high risk and other covered
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indication(s)
G0473
Face-to-face behavioral counseling for obesity, group (2-10), 30 minutes
G0475
HIV antigen/antibody, combination assay, screening
G0476
Infectious agent detection by nucleic acid (DNA or RNA); human papillomavirus
HPV), high-risk types (e.g., 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) for
cervical cancer screening, must be performed in addition to pap test
G0499
Hepatitis b screening in non-pregnant, high risk individual includes hepatitis b
surface antigen (hbsag) followed by a neutralizing confirmatory test for initially
reactive results, and antibodies to hbsag (anti-hbs) and hepatitis b core antigen
(anti-hbc)
G0513
Prolonged preventive service(s) (beyond the typical service time of the primary
procedure), in the office or other outpatient setting requiring direct patient contact
beyond the usual service; first 30 minutes (list separately in addition to code for
preventive service) (New code effective 01-01-2018)
G0514
Prolonged preventive service(s) (beyond the typical service time of the primary
procedure), in the office or other outpatient setting requiring direct patient contact
beyond the usual service; first 30 minutes (list separately in addition to code
G0513 for additional 30 minutes of preventive service) (New code effective 01-
01-2018)
G9873
First Medicare Diabetes Prevention Program (MDPP) core session was attended
by an MDPP beneficiary under the MDPP Expanded Model (EM). A core session
is an MDPP service that: (1) is furnished by an MDPP supplier during months 1
through 6 of the MDPP services period; (2) is approximately 1 hour in length;
and (3) adheres to a CDC-approved DPP curriculum for core sessions
G9874
Four total Medicare Diabetes Prevention Program (MDPP) core sessions were
attended by an MDPP beneficiary under the MDPP Expanded Model (EM). A
core session is an MDPP service that: (1) is furnished by an MDPP supplier
during months 1 through 6 of the MDPP services period; (2) is approximately 1
hour in length; and (3) adheres to a CDC-approved DPP curriculum for core
sessions.
G9875
Nine total Medicare Diabetes Prevention Program (MDPP) core sessions were
attended by an MDPP beneficiary under the MDPP Expanded Model (EM). A
core session is an MDPP service that: (1) is furnished by an MDPP supplier
during months 1 through 6 of the MDPP services period; (2) is approximately 1
hour in length; and (3) adheres to a CDC-approved DPP curriculum for core
sessions
G9876
Two Medicare Diabetes Prevention Program (MDPP) core maintenance
sessions (MS) were attended by an MDPP beneficiary in months (mo) 7-9 under
the MDPP Expanded Model (EM). A core maintenance session is an MDPP
service that: (1) is furnished by an MDPP supplier during months 7 through 12 of
the MDPP services period; (2) is approximately 1 hour in length; and (3) adheres
to a CDC-approved DPP curriculum for maintenance sessions. The beneficiary
did not achieve at least 5% weight loss (WL) from his/her baseline weight, as
measured by at least one in-person weight measurement at a core maintenance
session in months 7-9
G9877
Two Medicare Diabetes Prevention Program (MDPP) core maintenance
sessions (MS) were attended by an MDPP beneficiary in months (mo) 10-12
under the MDPP Expanded Model (EM). A core maintenance session is an
MDPP service that: (1) is furnished by an MDPP supplier during months 7
through 12 of the MDPP services period; (2) is approximately 1 hour in length;
and (3) adheres to a CDC-approved DPP curriculum for maintenance sessions.
The beneficiary did not achieve at least 5% weight loss (WL) from his/her
baseline weight, as measured by at least one in-person weight measurement at
a core maintenance session in months 10-12
G9878
Two Medicare Diabetes Prevention Program (MDPP) core maintenance
sessions (MS) were attended by an MDPP beneficiary in months (mo) 7-9 under
the MDPP Expanded Model (EM). A core maintenance session is an MDPP
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service that: (1) is furnished by an MDPP supplier during months 7 through 12 of
the MDPP services period; (2) is approximately 1 hour in length; and (3) adheres
to a CDC-approved DPP curriculum for maintenance sessions.The beneficiary
achieved at least 5% weight loss (WL) from his/her baseline weight, as
measured by at least one in-person weight measurement at a core maintenance
session in months 7-9
G9879
Two Medicare Diabetes Prevention Program (MDPP) core maintenance
sessions (MS) were attended by an MDPP beneficiary in months (mo) 10-12
under the MDPP Expanded Model (EM). A core maintenance session is an
MDPP service that: (1) is furnished by an MDPP supplier during months 7
through 12 of the MDPP services period; (2) is approximately 1 hour in length;
and (3) adheres to a CDC-approved DPP curriculum for maintenance
sessions.The beneficiary achieved at least 5% weight loss (WL) from his/her
baseline weight, as measured by at least one in-person weight measurement at
a core maintenance session in months 10-12
G9880
The MDPP beneficiary achieved at least 5% weight loss (WL) from his/her
baseline weight in months 1-12 of the MDPP services period under the MDPP
Expanded Model (EM). This is a one-time payment available when a beneficiary
first achieves at least 5% weight loss from baseline as measured by an in-person
weight measurement at a core session or core maintenance session
G9881
The MDPP beneficiary achieved at least 9% weight loss (WL) from his/her
baseline weight in months 1-24 under the MDPP Expanded Model (EM). This is
a one-time payment available when a beneficiary first achieves at least 9%
weight loss from baseline as measured by an in-person weight measurement at
a core session, core maintenance session, or ongoing maintenance session
G9882
Two Medicare Diabetes Prevention Program (MDPP) ongoing maintenance
sessions (MS) were attended by an MDPP beneficiary in months (mo) 13-15
under the MDPP Expanded Model (EM). An ongoing maintenance session is an
MDPP service that: (1) is furnished by an MDPP supplier during months 13
through 24 of the MDPP services period; (2) is approximately 1 hour in length;
and (3) adheres to a CDC-approved DPP curriculum for maintenance
sessions.The beneficiary maintained at least 5% weight loss (WL) from his/her
baseline weight, as measured by at least one in-person weight measurement at
an ongoing maintenance session in months 13-15
G9883
Two Medicare Diabetes Prevention Program (MDPP) ongoing maintenance
sessions (MS) were attended by an MDPP beneficiary in months (mo) 16-18
under the MDPP Expanded Model (EM). An ongoing maintenance session is an
MDPP service that: (1) is furnished by an MDPP supplier during months 13
through 24 of the MDPP services period; (2) is approximately 1 hour in length;
and (3) adheres to a CDC-approved DPP curriculum for maintenance sessions.
The beneficiary maintained at least 5% weight loss (WL) from his/her baseline
weight, as measured by at least one in-person weight measurement at an
ongoing maintenance session in months 16-18
G9884
Two Medicare Diabetes Prevention Program (MDPP) ongoing maintenance
sessions (MS) were attended by an MDPP beneficiary in months (mo) 19-21
under the MDPP Expanded Model (EM). An ongoing maintenance session is an
MDPP service that: (1) is furnished by an MDPP supplier during months 13
through 24 of the MDPP services period; (2) is approximately 1 hour in length;
and (3) adheres to a CDC-approved DPP curriculum for maintenance sessions.
The beneficiary maintained at least 5% weight loss (WL) from his/her baseline
weight, as measured by at least one in-person weight measurement at an
ongoing maintenance session in months 19-21
G9885
Two Medicare Diabetes Prevention Program (MDPP) ongoing maintenance
sessions (MS) were attended by an MDPP beneficiary in months (mo) 22-24
under the MDPP Expanded Model (EM). An ongoing maintenance session is an
MDPP service that: (1) is furnished by an MDPP supplier during months 13
through 24 of the MDPP services period; (2) is approximately 1 hour in length;
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and (3) adheres to a CDC-approved DPP curriculum for maintenance sessions.
The beneficiary maintained at least 5% weight loss (WL) from his/her baseline
weight, as measured by at least one in-person weight measurement at an
ongoing maintenance session in months 22-24
G9890
Bridge Payment: A one-time payment for the first Medicare Diabetes Prevention
Program (MDPP) core session, core maintenance session, or ongoing
maintenance session furnished by an MDPP supplier to an MDPP beneficiary
during months 1-24 of the MDPP Expanded Model (EM) who has previously
received MDPP services from a different MDPP supplier under the MDPP
Expanded Model. A supplier may only receive one bridge payment per MDPP
beneficiary
J1050
Injection, medroxyprogesterone acetate, 1 mg
J3490
Unclassified drug
J3530
Nasal vaccine inhalation
J7296
Levonorgestrel-releasing intrauterine contraceptive system, (Kyleena), 19.5 mg
(New code effective 01-01-2018)
J7297
Levonorgestrel-releasing intrauterine contraceptive system, 52mg, 3 year
duration
J7298
Levonorgestrel-releasing intrauterine contraceptive system, 52 mg, 5 year
duration
J7300
Intrauterine copper contraceptive
J7301
Levonorgestrel-releasing intrauterine contraceptive system, 13.5 mg
J7307
Etonogestrel (contraceptive) implant system, including implant and supplies
P3000
Screening Papanicolaou smear, cervical or vaginal, up to 3 smears, by
technician under physician supervision
P3001
Screening Papanicolaou smear, cervical or vaginal, up to 3 smears, requiring
interpretation by physician
Q0091
Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical
or vaginal smear to laboratory
Q2034
Influenza virus vaccine, split virus, for intramuscular use (Agriflu)
Q2035
Influenza virus vaccine, split virus, when administered to individuals 3 years of
age and older, for intramuscular use (AFLURIA)
Q2036
Influenza virus vaccine, split virus, when administered to individuals 3 years of
age and older, for intramuscular use (FLULAVAL)
Q2037
Influenza virus vaccine, split virus, when administered to individuals 3 years of
age and older, for intramuscular use (FLUVIRIN)
Q2038
Influenza virus vaccine, split virus, when administered to individuals 3 years of
age and older, for intramuscular use (Fluzone)
Q2039
Influenza virus vaccine not otherwise specified
Q9984
Levonorgestrel-releasing intrauterine contraceptive system (Kyleena), 19.5 mg
(Code deleted effective 01-01-2018)
S0265
Genetic counseling, under physician supervision, each 15 minutes
S0285
Colonoscopy consultation performed prior to a screening colonoscopy procedure
S0302
Completed early periodic screening diagnosis and treatment (EPSDT) service
(list in addition to code for appropriate evaluation and management service)
S3620
Newborn metabolic screening panel, includes test kit, postage and the laboratory
tests specified by the state for inclusion in this panel (e.g., galactose;
hemoglobin, electrophoresis; hydroxyprogesterone, 17-d; phenylanine (PKU);
and thyroxine, total)
S3645
HIV-1 antibody testing of oral mucosal transudate
S4981
Insertion of levonorgestrel-releasing intrauterine system
S8990
Physical or manipulative therapy performed for maintenance rather than
restoration
S9131
Physical therapy; in the home, per diem
S9443
Lactation classes, nonphysician provider, per session
S9470
Nutritional counseling, dietitian visit
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V5008
Hearing screening
Code Group 1
Interventions: Select the appropriate diagnosis code from the following:
ICD-10-CM
Diagnosis
Codes
Description
Z00.00
Encounter for general adult medical examination without abnormal findings
Z00.01
Encounter for general adult medical examination with abnormal findings
Z00.110
Health examination for newborn under 8 days old
Z00.111
Health examination for newborn 8 to 28 days old
Z00.121
Encounter for routine child health examination with abnormal findings
Z00.129
Encounter for routine child health examination without abnormal findings
Z00.3
Encounter for examination for adolescent development state
Z00.8
Encounter for other general examination
Z01.30
Encounter for examination of blood pressure without abnormal findings
Z01.31
Encounter for examination of blood pressure with abnormal findings
Z01.411
Encounter for gynecological examination (general) (routine) with abnormal
findings
Z01.419
Encounter for gynecological examination (general) (routine) without abnormal
findings
Z01.42
Encounter for cervical smear to confirm findings of recent normal smear
following initial abnormal smear
Z11.1
Encounter for screening for respiratory tuberculosis
Z11.3
Encounter for screening for infections with a predominantly sexual mode of
transmission
Z11.4
Encounter for screening for human immunodeficiency virus [HIV]
Z11.51
Encounter for screening for human papillomavirus (HPV)
Z11.59
Encounter for screening for other viral diseases
Z11.8
Encounter for screening for other infectious and parasitic diseases
Z12.10
Encounter for screening for malignant neoplasm of intestinal tract, unspecified
Z12.11
Encounter for screening for malignant neoplasm of colon
Z12.12
Encounter for screening for malignant neoplasm of rectum
Z12.13
Encounter for screening for malignant neoplasm of small intestine
Z12.31
Encounter for screening mammogram for malignant neoplasm of breast
Z12.39
Encounter for other screening for malignant neoplasm of breast
Z12.4
Encounter for screening for malignant neoplasm of cervix
Z12.5
Encounter for screening for malignant neoplasm of prostate
Z13.1
Encounter for screening for diabetes mellitus
Z13.220
Encounter for screening for lipoid disorders
Z13.4
Encounter for screening for certain developmental disorders in childhood
Z13.6
Encounter for screening for cardiovascular disorders
Z13.820
Encounter for screening for osteoporosis
Z13.88
Encounter for screening for disorder due to exposure to contaminants
Z23
Encounter for immunization
Z31.5
Encounter for procreative genetic counseling
Z71.3
Dietary counseling and surveillance
Z71.7
Human immunodeficiency virus [HIV] counseling
Z71.83
Encounter for non-procreative genetic counseling
Z73.9
Problem related to life management difficulty, unspecified
Z76.1
Encounter for health supervision and care of foundling
Z76.2
Encounter for health supervision and care of other healthy infant and child
Z76.81
Expectant parent(s) prebirth pediatrician visit
Z80.0
Family history of malignant neoplasm of digestive organs
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Z80.3
Family history of malignant neoplasm of breast
Z80.41
Family history of malignant neoplasm of ovary
Z80.42
Family history of malignant neoplasm of prostate
Z82.62
Family history of osteoporosis
Z83.3
Family history of diabetes mellitus
Z83.42
Family history of familial hypercholesterolemia
Z83.71
Family history of colonic polyps
Z85.3
Personal history of malignant neoplasm of breast
Z85.43
Personal history of malignant neoplasm of ovary
Code Group 2
Fall Prevention: Use the following diagnosis codes only in combination with CPT codes 97110, 97112,
97113, 97116, 97150, 97161, 97162, 97163, 97164, 97530, G0159, S8990, S9131
ICD-10-CM
Diagnosis
Codes
Description
M62.81
Muscle weakness (generalized)
R26.81
Unsteadiness on feet
R54
Age-related physical debility
Z91.81
History of falling
Code Group 3
Lung Cancer Screening: Use the following diagnosis codes only in combination with CPT codes 71250,
G0296, G0297, S8032
ICD-10-CM
Diagnosis
Codes
Description
Z12.2
Encounter for screening for malignant neoplasm of respiratory organs
Z87.891
Personal history of nicotine dependence
Code Group 4
Contraceptives-Injection: Use the following diagnosis codes only in combination with codes J1050 or
96372
ICD-10-CM
Diagnosis
Codes
Description
Z30.40
Encounter for surveillance of contraceptives, unspecified
Z30.42
Encounter for surveillance of injectable contraceptive
Z30.49
Encounter for surveillance of other contraceptives
Code Group 5
Pathology/Follow-up Confirmation: Use the following diagnosis codes only in combination with CPT
codes 58340, 74740, 76830, 88302
ICD-10-CM
Diagnosis
Codes
Description
Z30.2
Encounter for sterilization
Z30.42
Encounter for surveillance of injectable contraceptive
Z30.49
Encounter for surveillance of other contraceptives
Z30.8
Encounter for other contraceptive management
Z30.9
Encounter for contraceptive management, unspecified
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Code Group 6
Contraceptive-Intrauterine Contraceptive Device (i.e., Kyleena): Use the following diagnosis codes only in
combination with HCPCS code J3490 and NDC# 50419-424-01 (aka 50419042401) prior to 07-01-2017.
ICD-10-CM
Diagnosis
Codes
Description
Z30.430
Encounter for insertion of intrauterine contraceptive device
Z30.431
Encounter for removal of intrauterine contraceptive device
Z30.433
Encounter for removal and reinsertion of intrauterine contraceptive device
Code Group 7
Blood Pressure Screening Outside Clinical Setting: Use the following diagnosis code only in combination
with CPT codes 93784, 93786, 93788, 93790; or HCPCS codes A4660, A4663, A4670
ICD-10-CM
Diagnosis
Codes
Description
R03.0
Elevated blood pressure reading, without diagnosis of hypertension
*Current Procedural Terminology (CPT
®
) ©2017 American Medical Association: Chicago, IL.
References
1. Advisory Committee on Heritable Disorders in Newborns and Children. Recommended Uniform
Screening Panel. Accessed December 6, 2017. Available at: https://www.hrsa.gov/advisory-
committees/heritable-disorders/rusp/index.html
2. American Academy of Pediatrics. Recommendations for Pediatric Preventive Health Care. Periodicity
Schedule. Accessed on December 6, 2017. Available at: https://www.aap.org/en-us/professional-
resources/practice-support/Periodicity/Periodicity%20Schedule_FINAL.pdf
3. Centers for Disease Control and Prevention. Immunization Schedules. Accessed on December 6, 2017.
Available at:http://www.cdc.gov/vaccines/schedules/index.html
4. Centers for Disease Control and Prevention. Vaccine Recommendations of the ACIP. Accessed
December 6, 2017. Available at:http://www.cdc.gov/vaccines/hcp/acip-recs/index.html
5. Health and Human Services. Preventive Services Covered under the Affordable Care Act. Accessed on
December 6, 2017. Available at:https://www.hhs.gov/healthcare/about-the-aca/preventive-care/index.html
6. Health and Human Services. Center for Consumer Information and Insurance Oversight. Affordable Care
Act Implementation. FAQs-Set 12. Accessed December 6, 2017. Available
at:https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/aca_implementation_faqs12.html
7. Health and Human Services. The Center for Consumer Information and Insurance Oversight. Fact Sheets
and Frequently Asked Questions. Accessed on December 6, 2017. Available at:
https://www.cms.gov/cciio/Resources/Fact-Sheets-and-FAQs/index.html#Prevention
8. Institute of Medicine. Clinical Preventive Services for Women-Closing the Gaps. Accessed December 6,
2017. Available at: http://nationalacademies.org/HMD/Reports/2011/Clinical-Preventive-Services-for-
Women-Closing-the-Gaps.aspx
9. United States Department of Health and Human Services Administration. Womens Preventive Services
Guidelines. Accessed December 6, 2017. Available at: https://www.hrsa.gov/womens-
guidelines/index.html
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10. United States Preventive Services Task Force. USPSTF A and B Recommendations. Accessed
December 6, 2017. Available at:http://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-
b-recommendations/
11. United States Preventive Services Task Force. Recommendations for Primary Care Practice. Published
Recommendations. Accessed December 6, 2017. Available
at:https://www.uspreventiveservicestaskforce.org/Page/Name/recommendations
.
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