Preventive Care Services Summary
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1 Preventive Care Services Summary Below is a list of preventive services along with the diagnoses and procedure codes that Community Health Options has determined to meet or exceed the requirements and recommendations issued by the Affordable Care Act (ACA) as of the date this was last updated. This document will be updated periodically to reflect the most up-to-date requirements. Services may be subject to Prior Approval or other Medical Management criteria. Description Applies to CPT Code ICD 10 Code Notes Abdominal Aortic Aneurysm Males only (with any Z87.891, Z00.00, F17.210, 1 PER LIFETIME Screening history of smoking) F17.211, F17.213, F17.218, Ages years F One in a lifetime Alcohol Misuse screening and Age 18 and over 99408, Z00.00, Z13.89 counseling Aspirin use to prevent Men N/A N/A Covered under E/M cardiovascular disease for men and women of certain ages Women High Blood Pressure screening Age 18 and over N/A N/A Covered under E/M in adults Cholesterol screening for adults of certain ages or at higher risk Colorectal Cancer screening for adults over 50 All men age 35 and older Men ages 20 to 35 who have heart disease or risk factors for heart disease Women age 20 and older who have heart disease or risk factors for heart disease 80061, 82465, 83718, 83719, 83721, and over 00810, 44388, 44389, 44392, 44393, 44394, 45300, 45305, 45308, 45309, 45315, 45320, 45330, 45331, 45332, 45333, 45338, 45339, 45341, 45342, Z00.00, Z00.01, Z Z00.00, Z00.01, Z12.0, Z12.10, Z12.11, Z12.12, Z12.13, Z12.79, Z12.89, Z12.9, Z80.0, Z80.9, Z83.71, Revised 11/13/2017 1
2 Depression screening for adults Diabetes (Type 2) screening for adults with high blood pressure Diet counseling for adults at higher risk for chronic disease HIV screening for everyone ages 15 to 65, and other ages at increased risk Immunization vaccines for adults--doses, recommended ages, and recommended populations vary: 45378, 45380, 45381, 45383, 45384, 45385, 82270, 82272, 82274, 88304, 88305, 99152, 99153, 99156, 99157, G0104, G0105, G0106, G0120, G0121, G0122, G0328 Z83.79, Z85.00, Z85.038, Z85.048, Z Age 18 and over G0444, Z , 82948, 82950, 82951, 82952, , 97803, 97804, S9470, 99401, 99403, , 86701, 86702, 86703, 87389, 87534, 87535, 87536, 87537, 87538, 87539, 87806, G0432, G0433, G0435, G , 90461, 90471, 90472, 90473, Hepatitis A 90632, 90633, 90634, Hepatitis B 90647, 90648, 90739, 90740, 90746, 90747, Hepatitis C Adults born between 86803, G0472, 86804, per lifetime 1945 and per lifetime Herpes Zoster Ages Human Papillomavirus Ages , 90650, Influenza (Flu Shot) 90630, 90653, , , , 90682, , Measles, Mumps, Rubella 90707, Meningococcal 90620, 90621, 90644, 90733, Pneumococcal 90670, 90732, Z13.1 Z724 Revised 11/13/2017 2
3 Tetanus, Diphtheria, Pertussis , 90714, 90715, Varicella Obesity screening and counseling for all adults Z00.00, Z00.01, Z00.121, Z00.129, Z13.89 Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk , G0445 Syphilis screening for all adults at higher risk Tobacco Use screening for all adults and cessation interventions for tobacco users 86592, O09.00, O09.01, O09.02, O09.93, Z11.2, Z11.3, Z33.1, Z34.00, Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82, Z34.83, Z34.90, Z34.91, Z34.92, Z , Lung Cancer Screening Ages G0297 F17.200, F17.210, F17.211, F17.213, F17.218, F17.219, Z Preventive Health Services Applies to CPT Codes ICD 10 Codes Notes Specific to Women Anemia screening on a routine basis for pregnant women Pregnant females 85014, O09.00, O09.01, O09.02, Revised 11/13/2017 3
4 Breast Cancer Genetic Test Counseling (BRCA) for women at higher risk for breast cancer Breast Cancer Mammography screenings every 1 to 2 years for women over 40 Breast Cancer Chemoprevention counseling for women at higher risk Breastfeeding comprehensive support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women Cervical Cancer screening for sexually active women Chlamydia Infection screening for younger women and other women at higher risk Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans Z3480, Z34.81, Z34.82, Z34.92, Z34.93 Females , Z00.00, Z00.01, Z15.01, Z80.3, Z80.41, Z80.49, Z85.43 Females 40 and over G0202, per year Females , , , 99411, Females S9443, E0602, E0603, E0604, A4281-A4286, Females , 87623, 87624, 87625, G0101, G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148 Females 86631, 86632, 87110, 87270, 87320, , , Females STERILIZATION , 58600, 58605, 58611, 58615, 58670, 58671, A4264 CONTRACEPTIVES , A4261, A4266, J7297, J7298, J7300, J7301, J7307, J1050, 11976, 58300, 58301, S4981, S4989 Anesthesia , 00940, Z80.3, Z80.41 Z39.1 Z00.00, Z00.01, Z01.411, Z01.419, Z01.42, Z11.51, Z12.4 Z00.00, Z00.01, Z11.3, Z11.8, Z11.9, Z20.2 Z30.011, Z30.013, Z30.014, Z3.0018, Z30.019, Z30.012, Z30.09, Z30.430, Z30.431, Z30.432, Z30.433, Z30.40, Z30.41, Z30.42, Z30.49, Z30.8, Z30.9, Z30.2, Z30.015, Z30.016, Z30.017, Z30.44, Z30.45, Z30.46, Z31.7 Revised 11/13/2017 4
5 sponsored by certain exempt religious employers. Domestic and interpersonal violence screening and counseling for all women Folic Acid supplements for women who may become pregnant Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes Gonorrhea screening for all women at higher risk 00942, 00950, 00952, 01960, 01961, 01965, 01966, 01967, Females N/A N/A Covered under E/M Females N/A N/A Pharmacy Benefit Pregnant females 82947, 82948, 82950, 82951, 82952, O09.00, O09.01, O0.902, Z34.80, Z34.81, Z34.82, Z34.92, Z34.93, O16.5, O24.415, O Females 87590, 87591, 87592, O09.00, O09.01, O0.902, Z34.80, Z34.81, Z34.82, Z34.92, Z34.93, O16.5, O24.415, O Revised 11/13/2017 5
6 Hepatitis B screening for pregnant women at their first prenatal visit HIV screening and counseling for sexually active women Human Papillomavirus (HPV) DNA Test Osteoporosis screening for women over age 60 depending on risk factors Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk Pregnant females 86706, 87340, 87341, 87515, 87516, Females 86689, 86701, 86702, 86703, 87389, 87534, 87535, 87536, 87537, 87538, 87539, G0432, G0433, G0435 Females 30 and older with normal cytology results Females 60 and over 76977, 77080, 77081, 77082, G0130 O09.00, O09.01, O0.902, Z34.80, Z34.81, Z34.82, Z34.92, Z34.93, O16.5, O24.415, O , Z00.00, Z00.01, Z01.411, Z01.419, Z01.42, Z11.51, Z12.4 Z82.62, Z00.00, Z00.01, Z Females O09.00, O09.01, O09.02, Z3480, Z34.81, Z34.82, Z34.92, Z every 3 years Revised 11/13/2017 6
7 Sexually Transmitted Infections counseling for sexually active women Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users Urinary tract or other infection screening for pregnant women Well-woman visits to get recommended services for women under 65 Preventive Health Services Specific to Children Autism screening for children at 18 and 24 months Behavioral assessments for children at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. Blood Pressure Screening for children Cervical Dysplasia screening for sexually active females Females , G , 99407, G0436, G0437 Pregnant females O09.00, O09.01, O09.02, Z3480, Z34.81, Z34.82, Z34.92, Z , , G0402, G0438, G per year Applies To CPT Codes ICD Codes Notes 1-2 Years Z00.00, Z00.01, Z00.121, Z00.129, Z Age ranges N/A N/A Covered under E/M Females , , 87623, G0101, G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148 N/A N/A Covered under E/M Z00.00, Z00.01, Z01.411, Z01.419, Z01.42, Z11.51, Z12.4 Revised 11/13/2017 7
8 Depression screening for adolescents Developmental screening for children under age 17 Dyslipidemia screening for children at higher risk of lipid disorders at the following ages: 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. Fluoride Chemoprevention supplements for children without fluoride in their water source Gonorrhea preventive medication for the eyes of all newborns Hearing screening for all newborns Height, Weight and Body Mass Index measurements for children. Hematocrit or Hemoglobin screening for children Hemoglobinopathies or sickle cell screening for newborns HIV screening for adolescents at higher risk **Hypothyroidism screening for newborns Immunization vaccines for children from birth to age 18 doses, recommended ages, and recommended populations vary: G0444, Z years Z00.00, Z00.01, Z00.121, Z00.129, Z years 80061, 82465, 83718, 83719, Z00.00, Z00.01, Z00.121, 83721, Z00.129, Z N/A N/A Covered under E/M or Pharmacy Benefit N/A N/A Part of Newborn Care (bundled) or Pharmacy Benefit 0-90 DAYS V5008, 92551, 92558, 92585, 92586, 92587, N/A N/A Covered under E/M 0-90 DAYS 85014, Z00.00, Z00.01, Z00.121, Z00.129, Z DAYS S3850, 83020, 83021, 83030, 83033, , 86701, 86702, 86703, 87389, 87534, 87535, 87536, 87537, 87538, 87539, G0432, G0433, G DAYS 84437, , 90461, 90471, 90472, 90473, Revised 11/13/2017 8
9 Diphtheria, Tetanus, Pertussis , 90714, 90715, Haemophilus influenzae type B Hepatitis A 90632, 90633, 90634, Hepatitis B 90647, 90648, 90743, Human Papillomavirus 90649, 90650, Inactivated Poliovirus Influenza (Flu Shot) 90630, 90653, , , , 90682, , Measles, Mumps, Rubella 90707, Meningococcal 90620, 90621, 90644, 90733, Pneumococcal 90670, 90732, Rotavirus 90680, Varicella Iron supplements for children N/A N/A Pharmacy Benefit ages 6 to 12 months at risk for anemia Lead screening for children at risk of exposure Z00.00, Z00.01, Z00.121, Z00.129, Z13.88, Z Medical History for all children N/A N/A Covered under E/M throughout development at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. Obesity screening and counseling Z00.00, Z00.01, Z00.121, Z00.129, Z13.89 Oral Health risk assessment for young children Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years. N/A N/A Included in Pediatric Dental Benefits for plans that include Pediatric Dental. Phenylketonuria (PKU) screening for this genetic disorder in newborns 0-1 years S3620, Revised 11/13/2017 9
10 Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents at higher risk Tuberculin testing for children at higher risk of tuberculosis at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to , G R76.11, R76.12, Z00.121, Z00.129, Z11.1 years. Vision screening. 1-5 years 99172, Z00.00, Z00.01, Z00.121, Z00.129, Z Revised 11/13/
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