NOTE: Please append modifier 33 when indicated. If modifier 33 is not appended, regular plan benefits will be applied.

Transcription

1 Policy name: Preventive Health Guidelines - Women The following chart contains procedure and diagnosis code combinations that identify services covered under HMSA's Preventive Health s policy. * For professional claims, the applicable code must be identified as the primary line diagnosis to ensure appropriate application of benefits. * You will not receive the maximum payment allowed for these services under the new guidelines if the code combinations below are not submitted on your claim. NOTE: Please append modifier when indicated. If modifier is not appended, regular plan benefits will be applied. Preventive Well-Woman exam G0101 Cervical or vaginal cancer screening; pelvic and clinical breast examination Z Z Breast Cancer Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed G0202 Cervical Cancer Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed Cytopathology, cervical or vaginal screening by various methods and to report physician interpretation services Z12.31 Z80.3 Z85.3 Z Z Z01.42 Z12.4 G0123-G0124 G0141 G0143-G0145 G0147-G0148 Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, screening by cytotechnologist under physician supervision P3000 P3001 Screening Papanicolaou smear, cervical or vaginal, up to 3 smears, by technician under physician supervision Screening Papanicolaou smear, cervical or vaginal, up to 3 smears, requiring interpretation by physician Chlamydia Chlamydia Z11.8 Colorectal Cancer Chlamydia, lgm Culture, chlamydia, any source Chlamydia trachomatis Chlamydia trachomatis, direct probe technique Chlamydia trachomatis, amplified probe technique Yes Z12.11 Z12.12 Z80.0 Z83.71 Z84.81 Updated on 3/21/2017 Preventive Health - Women - Coding Guidelines 1

2 Colorectal Cancer (con't) S0285 G0104 G0105 G0121 Colonoscopy consultation performed prior to a screening colonoscopy procedure Colorectal cancer screening; flexible sigmoidoscopy Colorectal cancer screening; colonoscopy on individual at high risk Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk Z12.11 Z12.12 Z80.0 Z83.71 Z Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) 451 with biopsy, single or multiple 452 with removal of foreign body 453 with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery 454 with control of bleeding (e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) 455 with directed submucosal injection(s), any substance 457 with decompression of volvulus, any method 458 with removal of tumor(s), polyp(s), or other lesion(s) by snare technique with dilation by balloon, 1 or more strictures with ablation of tumor(s), polyp(s), or other lesion(s) (includes preand post-dilation and guide wire passage, when performed) with endoscopic mucosal resection with band ligation(s) (eg, hemorrhoids) Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure) with removal of foreign body with biopsy, single or multiple with directed submucosal injection(s), any substance with control of bleeding (e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery with removal of tumor(s), polyp(s), or other lesion(s) by snare technique with dilation by balloon, 1 or more strictures with ablation of tumor(s), polyp(s), or other lesion(s) (includes preand post-dilation and guide wire passage, when performed) with endoscopic stent placement (includes pre- and post-dilation and guide wire passage, when performed) with endoscopic ultrasound examination with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s) with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube, when performed with band ligation(s) (eg, hemorrhoids) G0328 Colorectal cancer screening; fecal occult blood test, immunoassay, 1-3 simultaneous determinations Updated on 3/21/2017 Preventive Health - Women - Coding Guidelines 2

3 Colorectal Cancer (con't) Blood, occult, by peroxidase activity (e.g., guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (i.e., patient was provided 3 cards or single triple card for consecutive collection) Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum Level III - Surgical pathology, gross and microscopic examination Level IV - Surgical pathology, gross and microscopic examination Special stain including interpretation and report; Group I for microorganisms (eg, acid fast, methenamine silver) Special stain including interpretation and report; Group II, all other (eg, iron, trichrome), except stain for microorganisms, stains for enzyme constituents, or immunocytochemistry and immunohistochemistry Z12.11 Z12.12 Z80.0 Z83.71 Z Immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in addition to code for primary procedure) Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure Gonorrhea Culture, presumptive, pathogenic organisms, screening only Z Smear, primary source with interpretation; Gram or Giemsa stain for bacteria, fungi, or cell types Neisseria gonorrhoeae, direct probe technique Neisseria gonorrhoeae, amplified probe technique Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, quantification Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s) technique amplified probe(s) technique High Blood Pressure Yes Z01.30 Z01.31 Z13.6 HIV HTLV or HIV antibody, confirmatory test (e.g., Western Blot) HIV HIV HIV-1 and HIV-2, single assay (eff 1/1/2013) 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 Z11.4 Z20.6 Updated on 3/21/2017 Preventive Health - Women - Coding Guidelines 3

4 HIV con't (eff 1/1/2013) Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; HIV-1 Z11.4 Z (eff 1/1/2013) Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; HIV-2 G0432 Infectious agent antigen detection by enzyme immunoassay (EIA) technique, G04 Infectious agent antigen detection by enzyme-linked immunosorbent assay (ELISA) technique, antibody, HIV-1 or HIV-2, screening G0435 Infectious agent antigen detection by rapid antibody test of oral mucosa transudate, HIV-1 or HIV-2, screening G0475 HIV antigen/antibody, combination assay, screening Yes Counseling. Preventive medicine counseling and/or risk factor reduction Human papillomavirus testing Infectious agent detection by nucleic acid (DNA or RNA); human papillomavirus (HPV), high-risk types (eg, 16, 18, 31,, 35, 39, 45, 51, 52, 56, 58, 59, 68) Infectious agent detection by nucleic acid (DNA or RNA); human papillomavirus (HPV), types 16 and 18 only, includes type 45, if performed Z11.51 Z12.4 Z12.72 G0476 Infectious agent detection by nucleic acid (DNA or RNA); human papillomavirus HPV), high-risk types (e.g., 16, 18, 31,, 35, 39, 45, 51, 52, 56, 58, 59, 68) for cervical cancer screening, must be performed in addition to pap test Screening for hepatitis C virus (HCV) G0472 Hepatitis C antibody screening for individual at high risk and other covered indication(s) Z11.59 Z20.5 Z Screening for hepatitis B virus (HBV) Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; hepatitis B surface antigen (HBsAg) Infectiour agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; hepatitis B surface antigen (HBsAg) Z Hepatitis B core antibody (HBcAb); total Hepatitis B core antibody (HBcAb); IgM antibody Hepatitis B surface antibody (HBsAb) Lipid Disorders Lipid panel Z Cholesterol, serum or whole blood, total Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) Updated on 3/21/2017 Preventive Health - Women - Coding Guidelines 4

5 Syphilis Syphilis test, non-treponemal antibody; qualitative (e.g., VDRL, RPR, ART) Antibody; Treponema pallidum. Z11.3 Z72.51 Z72.52 Z72.53 Type 2 Diabetes Mellitus Glucose; quantitative, blood (except reagent strip) Yes Z Hemoglobin; by copper sulfate method, non-automated. Glycosylated (A1C). Osteoporosis Ultrasound bone density measurement and interpretation, peripheral site(s), any method Z Z Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine) Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine) appendicular skeleton (peripheral) (e.g., radius, wrist, heel) Depression Yes Z Brief emotional/behavioral assessment (eg, depression inventory, attentiondeficit/hyperactivity disorder [ADHD] scale, with scoring and documentation, per standardized instrument Alcohol Misuse Yes Z71.41 F10.10-F F10.20-F F F F F10.26-F10.27 F F Alcohol and/or substance (other than tobacco) abuse structured screening (e.g., AUDIT, DAST), and brief intervention (SBI) services. Differences in codes are time-based. Aspirin for the prevention of Cardiovascular disease (CVD) Folic acid to prevent neural tube defects Covered through HMSA's Pharmacy Benefit Manager with prescription Covered through HMSA's Pharmacy Benefit Manager with prescription Updated on 3/21/2017 Preventive Health - Women - Coding Guidelines 5

6 Tobacco Use and Tobacco Caused Disease Yes Z71.6 Z F F F F F F F F Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes Obesity Yes Z04.6 Z13.1 E66.01-E66.1 E66.8-E Counseling. Preventive medicine counseling and/or risk factor reduction Medical nutrition therapy; initial assessment and intervention, individual, faceto-face with the patient, each 15 minutes re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes group (2 or more individual(s)) each 30 minutes S9470 Healthy Diet Nutritional counseling, dietitian visit Yes Medical nutrition therapy; initial assessment and intervention, individual, faceto-face with the patient, each 15 minutes re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes Z71.3 with one of these additional diagnoses: E10.10-E10.9 E11.00-E11.9 E13.00-E13.9 I10 E71.30 E75.21-E75.22 E E75.3 E75.5-E75.6 E77.0-E77.9 E78.00-E78.70 E78.79-E78.9 E88.1-E88.2 E group (2 or more individual(s)) each 30 minutes S9452 Nutrition classes, nonphysician provider, per session S9470 Nutritional counseling, dietitian visit Updated on 3/21/2017 Preventive Health - Women - Coding Guidelines 6

7 Counseling for Sexually Transmitted Infections (STI) Yes Z70.0-Z70.1 Z71.7 Z71.89 Z72.51-Z72.53 Z77.21 Z77.9 Z Counseling. Preventive medicine counseling and/or risk factor reduction Contraceptive methods and counseling Removal, implantable contraceptive capsules Insertion, non-biodegradable drug delivery implant Removal, non-biodegradable drug delivery implant Removal with reinsertion, non-biodegradable drug delivery implant Diaphragm or cervical cap fitting with instructions Insertion of intrauterine device (IUD) Removal of intrauterine device (IUD) Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral Ligation or transection of fallopian tube(s), abdominal or vaginal approach, postpartum, unilateral or bilateral, during same hospitalization (separate procedure) Ligation or transection of fallopian tube(s) when done at the time of Occlusion of fallopian tube(s) by device (eg, band, clip, Falope ring) vaginal or suprapubic approach Laparoscopy, surgical; with fulguration of oviducts (with or without transection) Laparoscopy, surgical; with occlusion of oviducts by device (eg, band, clip, or Falope ring) Z Z Z30.02 Z30.09 Z30.2 Z30.40-Z30.42 Z Z30.4 Z30.44-Z30.46 Z30.49 Z30.8 Z30.9 J1050 J7297 J7298 Injection, medroxyprogesterone acetate, 1 mg Levonorgestrel-releasing intrauterine contraceptive system (Liletta), 52 mg Levonorgestrel-releasing intrauterine contraceptive system (Mirena), 52 mg J7300 J7301 Intrauterine copper contraceptive Levonorgestrel-releasing intrauterine contraceptive system (Skyla), 13.5 mg J7306 J7307 Levonorgestrel (contraceptive) implant system, including implants and supplies Etonogestrel (contraceptive) implant system, including implant and supplies S4981 S4989 Insertion of levonorgestrel-releasing intrauterine system Contraceptive intrauterine device (e.g., Progestacert IUD), including implants and supplies Updated on 3/21/2017 Preventive Health - Women - Coding Guidelines 7

8 Contraceptive methods and counseling con't Yes Z Z Z30.02 Z30.09 Z30.2 Z30.40-Z30.42 Z Z30.4 Z30.44-Z30.46 Z30.49 Z30.8 Z30.9 Additional contraceptives covered under HMSA s drug riders are processed through CVS Caremark: Contraceptive Diaphragms/Cervical Caps, Generic Oral Contraceptives, and Contraceptive Other Methods (e.g. ring and patch) including all FDA approved OTC female contraceptives Screening and counseling for interpersonal and domestic violence Counseling. Preventive medicine counseling and/or risk factor reduction Yes various Chemoprevention of breast cancer Yes Z80.3 Risk reduction of primary breast cancer Yes Z71.9 Covered through HMSA's Pharmacy Benefit Manager with prescription Updated on 3/21/2017 Preventive Health - Women - Coding Guidelines 8

9 Prevention of falls Yes Z91.81 Vitamin D supplementation for the prevention of falls Skin cancer Covered through HMSA's Pharmacy Benefit Manager with prescription Yes Z12.83 Z91.89 Lung Cancer G0297 Low dose CT scan (LDCT) for lung cancer screening Z12.2 Updated on 3/21/2017 Preventive Health - Women - Coding Guidelines 9