Patient Protection and Affordable Care Act

Transcription

1 Patient Protection and Affordable Care Act (Federal Health Care Reform) Introduction For employer groups and non-group members that renewed before January 1, 2011, benefit changes went into effect upon renewal on or after September 23, For employer groups and non-group members that renewed on or after January 1, 2011, these changes went into effect on January 1, 2011, except for the child dependent coverage change and durable medical equipment coinsurance changes as noted in the Preventive Services information below. Most preventive care services are covered with no cost sharing. Harvard Pilgrim members have no cost-sharing responsibility when preventive services are rendered by an in-network provider. Members may still be required to pay a copayment, deductible or coinsurance for preventive services received from out-of-network providers (PPO and POS plans), or for non-preventive services received in conjunction with a preventive services visit. Employer groups maintaining grandfathered status under the Patient Protection and Affordable Care Act, also known as Federal Health Care Reform, may be exempt from certain provisions. Coverage and Services All diagnosis codes of preventive, screening, counseling, or wellness, should be billed in the primary position when indicated. Preventive Care Harvard Pilgrim no longer imposes cost sharing on the following in-network preventive care services: Child Dependent Coverage Harvard Pilgrim provides coverage to child dependents until age 26. This change went into effect for all employer group renewals after September 23, Women s Preventive Services Effective for plan years renewing on or after August 1, 2012, Harvard Pilgrim will cover the following women s preventive services with no member cost sharing when rendered by a participating Harvard Pilgrim provider: Durable Medical Equipment There are no annual dollar limits for the durable medical equipment benefit. In addition, effective as of July 1, 2011, a minimum coinsurance of 20% was introduced for this benefit. If a plan already had coinsurance of 20% or greater for durable medical equipment purchased from a network provider, there is no change in the member cost sharing for this equipment (subject to regulatory approval for New Hampshire plans). Lifetime Limits There are no aggregate lifetime dollar limits or lifetime and annual dollar benefit limits on essential The following tables represent services, by category, that have been identified as preventive in nature. Rx Coverage Under the Member s Rx benefit, the following benefits are covered: and quantity limits apply. Harvard Pilgrim Health Care Provider Manual B.17 January 2016

2 Routine Health Screenings Abdominal Aortic Aneurysm Screening Once per lifetime Personal history of nicotine dependence Once per lifetime Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), real time with image documentation; complete Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), real time with image documentation; limited abdominal aortic aneurysm (AAA) screening Anemia, Iron Deficiency Anemia Screening ICD-9/10 codes Blood count; hematocrit (Hct) Covered when billed with one of the Blood count; hemoglobin (Hgb) Aspirin for the Prevention of Cardiovascular Disease Bacteriuria Screening Description the potential benefit due to a reduction in myocardial infarctions outweighs the potential harm due to an increase in gastrointestinal hemorrhage. the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage. Comments Urinalysis; bacteriuria screen, except by culture or dipstick Behavioral Counseling Interventions and Screening in Primary Care to Reduce Alcohol Misuse Alcoholism Encounter for screening for other disorder E&M services codes covered in full when counseling for aspirin use. Covered when billed with one of the Harvard Pilgrim Health Care Provider Manual B.18 January 2016

3 to 30 minutes. greater than 30 minutes. Behavioral Counseling to Prevent Sexually Transmitted Infections Description High-intensity behavioral counseling is recommended to prevent sexually transmitted infections (STIs) for all sexually active adolescents and for adults at increased risk for STIs. Comments Covered when billed separately or with an E&M service, included in Behavioral Counseling in Primary Care to Promote a Healthy Diet Inappropriate diet and eating habits Covered when billed separately or with an E&M service appended with Inappropriate diet and eating habits Covered when billed separately or with an E&M service appended with Nutritional counseling Medical nutrition therapy; initial assessment and intervention, indi- Medical nutrition therapy; re-assessment and intervention, individual, Medical nutrition therapy; group (2 or more individual(s), each 30 minutes Preventive medicine counseling or risk factor reduction Breast Cancer Screening Genetic Counseling and Evaluation for BRCA Testing Malignant neoplasm of specified parts of peritoneum Malignant neoplasm of peritoneum, unspecified Malignant neoplasm of fallopian tube Personal history of malignant of unspecified female genital organ Personal history of malignant neoplasm of ovary Family history of malignant neoplasm of breast Family history of malignant neoplasm of genital organs Family history of malignant neoplasm of ovary Genetic susceptibility to malignant neoplasm Personal history of malignant neoplasm of ovary Covered when billed separately or with an E&M service appended with Harvard Pilgrim Health Care Provider Manual B.19 January 2016

4 Family history of malignant neoplasm of breast Family history of malignant neoplasm of other genital organs Family history of malignant neoplasm of ovary Genetic susceptibility to malignant neoplasm of breast BRCA1, BRCA2 (breast cancer 1 and 2) (e.g., hereditary breast and ovarian cancer) gene analysis; full sequence analysis and common BRCA1, BRCA2 (breast cancer 1 and 2) (e.g., hereditary breast and BRCA1, BRCA2 (breast cancer 1 and 2) (e.g., hereditary breast and variants BRCA1 (breast cancer 1) (e.g., hereditary breast and ovarian cancer) - BRCA1 (breast cancer 1) (e.g., hereditary breast and ovarian cancer) gene analysis; known familial variant BRCA2 (breast cancer 2) (e.g., hereditary breast and ovarian cancer) gene analysis; full sequence analysis BRCA2 (breast cancer 2) (e.g., hereditary breast and ovarian cancer) gene analysis; known familial variant BRCA1, BRCA2 (breast cancer 1 and 2) (e.g., hereditary breast and ovarian cancer) gene analysis; full sequence analysis and full duplica- Hereditary breast cancer-related disorders (e.g., hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer); genomic sequence analysis panel, must include sequencing of at least Hereditary breast cancer-related disorders (e.g., hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer); Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate Harvard Pilgrim Health Care Provider Manual B.20 January 2016

5 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate Breastfeeding Primary Care Intervention and Equipment to Promote Breastfeeding E0602 E0603 Post-partum visit Home visit for newborn care Tubing for breast pump, replacement Adapter for breast pump, replacement Cap for breast pump bottle, replacement Breast shield and splash protector for use with breast pump, replacement Polycarbonate bottle for use with breast pump, replacement Locking ring for breast pump, replacement Breast pump, manual, any type Lactation classes Cervical Cancer Screening, Pap Smear Routine gynecological examination Encounter for Papanicolaou cervical smear to confirm of recent normal smear following initial abnormal smear Screening for malignant neoplasm of the cervix Encounter for gynecological examination (general) (routine) with abnormal Encounter for gynecological examination (general) (routine) without abnormal This is a purchase only item. Rental for 3 months, then pump must be returned to vendor at the end of the rental period. Covered when billed with the listed ICD-9/10 dx codes. Harvard Pilgrim Health Care Provider Manual B.21 January 2016

6 Encounter for cervical smear to confirm of recent normal smear following initial abnormal smear Encounter for screening for malignant neoplasm of the cervix G0101 G0123 Chlamydia Infection Screening Cytopathology codes cervical or vaginal. Infectious agent detection, by nucleic acid, pappillomavirus. Cervical or vaginal cancer screening; pelvic and clinical breast examination. Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, screening by cytotechnologist under physician supervision. Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, requiring interpretation by physician. Screening cytopathology smears, cervical or vaginal, performed by automated system, with manual rescreening, requiring interpretation by physician. 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. Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system, under physician supervision. 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. Screening cytopathology smears, cervical or vaginal, performed by automated system under physician supervision. Screening cytopathology smears, cervical or vaginal, performed by automated system with manual rescreening. Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory. Pregnancy dx codes Special screening examination for other specified chlamydial diseases Special screening examination for unspecified chlamydial disease Encounter for supervision of normal first pregnancy, unspecified trimester Encounter for supervision of other normal pregnancy, unspecified trimester Z33.1 Pregnant State, incidental Supervision of pregnancy with history of infertility, unspecified trimester Supervision of pregnancy with history of ectopic or molar pregnancy, unspecified trimester Supervision of pregnancy with other poor reproductive or obstetric history, first trimester Covered when billed with the listed ICD-9/10 dx codes. Covered when billed with the listed ICD-9/10 dx codes. Harvard Pilgrim Health Care Provider Manual B.22 January 2016

7 Supervision of pregnancy with grand multiparity, unspecified trimester Supervision of pregnancy with history of pre-term labor, first trimester Supervision of pregnancy with history of ectopic or molar pregnancy, unspecified trimester Supervision of pregnancy with other poor reproductive or obstetric history, first trimester Supervision of pregnancy with insufficient antenatal care, unspecified trimester Supervision of elderly primigravida, unspecified trimester Supervision of elderly multigravida, unspecified trimester Supervision of young primigravida, unspecified trimester Supervision of young multigravida, unspecified trimester Supervision of pregnancy resulting from assisted reproductive technology, unspecified trimester Supervision of pregnancy with history of in utero procedure during previous pregnancy, unspecified trimester Pregnancy with inconclusive fetal viability, not applicable or unspecified Supervision of other high risk pregnancies, unspecified trimester Supervision of high risk pregnancy, unspecified, unspecified trimester Encounter for gynecological examination (general) (routine) with abnormal Encounter for gynecological examination (general) (routine) without abnormal Encounter for screening for other infectious and parasitic diseases Encounter for screening for other infectious and parasitic diseases Antibody; Chlamydia. All preganant women dx codes Antibody; Chlamydia, IgM. Covered when billed with either a Culture, Chlamydia, any source. Infectious agent antigen detection by immunofluorescent technique; code). Chlamydia trachomatis. nique, qualitative or semiquantitative, multiple step method; Chlamydia trachomatis. Infectious agent Chlamydia pneumoniae. trachomatis, direct probe technique. trachomatis, amplified probe technique. trachomatis, quantification. Cholesterol Screening (Lipid Disorders Screening) Harvard Pilgrim Health Care Provider Manual B.23 January 2016

8 Screening for lipoid disorders Z Encounter for screening for lipoid disorders Lipid panel. This panel must include the following: Cholesterol, dx codes and additional criteria listed Cholesterol, serum or whole blood, total Triglycerides dx codes and additional criteria listed Colorectal Cancer Screening (Fecal Occult Blood Testing, Sigmoidoscopy or Colonoscopy) Note: Diagnosis must be billed in the primary position. Small intestine to ulcerative colitis, unspecified Personal history of malignant neoplasm of unspecified site in gastrointestinal tract Personal history of malignant neoplasm of large intestine Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus History of colonic polyps Family history of malignant neoplasm of gastrointestinal tract Family hx CA NOS Family history, colonic polyps Family history, other digestive disorders Screening for malignant neoplasm of the rectum CA screening NEC Special screening for malignant neoplasms, intestine, unspecified Special screening for malignant neoplasms, colon Special screening for malignant neoplasms, small intestine CA screening NOS Ulcerative (chronic) pancolitis without complications Other ulcerative colitis without complications Ulcerative (chronic) proctitis without complications Ulcerative (chronic) rectosigmoiditis without complications Inflammatory polyps of colon without complications Harvard Pilgrim Health Care Provider Manual B.24 January 2016

9 Left sided colitis without complications Ulcerative colitis, unspecified, without complications Personal history of malignant neoplasm of unspecified digestive organ Personal history of other malignant neoplasm of large intestine Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus Personal history of colonic polyps Family history of malignant neoplasm, unspecified Family history of colonic polyps Family history of other diseases of the digestive system Z12.12 Encounter for screening for malignant neoplasm of rectum Z12.10 Encounter for screening for malignant neoplasm of other sites Encounter for screening for malignant neoplasm of intestinal tract, unspecified Z12.11 Encounter for screening for malignant neoplasm of colon Z12.13 Encounter for screening for malignant neoplasm of small intestine Encounter for screening for malignant neoplasm, site unspecified Revenue Codes Description Pharmacy Anesthesia Recovery room Comments one of the ICD 9/10 dx codes listed Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum. Colon endoscopy. Colonoscopy through stoma; with biopsy, single or multiple. Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery. Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique. Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique. Proctosigmoidoscopy, rigid; with biopsy, single or multiple. Proctosigmoidoscopy, rigid; with biopsy, single or multiple. Proctosigmoidoscopy, rigid; with removal of single tumor, polyp, or other lesion by hot biopsy forceps or bipolar cautery. Harvard Pilgrim Health Care Provider Manual B.25 January 2016

10 G0106 G0120 G0121 Proctosigmoidoscopy, rigid; with removal of single tumor, polyp, or other lesion by snare technique. Proctosigmoidoscopy, rigid; with removal of multiple tumors, polyps, or other lesions by hot biopsy forceps, bipolar cautery or snare technique. Proctosigmoidoscopy, rigid; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique (e.g., laser). Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen(s) by brushing or washing. Sigmoidoscopy, flexible; with biopsy, single or multiple. Sigmoidoscopy, flexible; with removal of foreign body. Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery. Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique. Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique. Sigmoidoscopy, flexible; with endoscopic ultrasound examination. Sigmoidoscopy, flexible; with transendoscopic ultrasound guided 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). Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple. Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique. Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery. Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique. Blood, occult, by peroxidase activity (e.g., guaiac), qualitative; feces, consecutive collected specimens with singe determination, for colorectal neoplasm screening (i.e., patient was provided three cards or single triple card for consecutive collection. Blood, occult, by peroxidase activity (e.g., guaiac), qualitative, feces, 1-3 simultaneous determinations, performed for other than colorectal neoplasm screening. Blood, occult, by fecal hemoglobin determined by immunoassay, qualitative, feces, 1-3 simultaneous determinations. Colorectal cancer screening; flexible sigmoidoscopy. Colorectal cancer screening; colonoscopy of individual at high risk. oscopy, barium enema. copy, barium enema. Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk. one of the ICD-9/10 dx codes listed Harvard Pilgrim Health Care Provider Manual B.26 January 2016

11 G0122 J3010 Contraception Colorectal cancer screening; barium enema. Colorectal cancer screening; fecal-occult blood test, immunoassay, 1-3 simultaneous determinations. Injection, meperidine HCl, per 100 mg. Injection, fentanyl citrate, 0.1 mg. Insertion, implantable contraceptive capsules Removal, implantable contraceptive capsules Removal with reinsertion, implantable contraceptive capsules Injection, anesthetic agent, paracervical (uterine) nerve Cervical cap for contraceptive use Permanent implantable contraceptive intratubal occlusion device(s) and delivery system Injection, medroxyprogesterone acetate, 1 mg year duration year duration Intrauterine copper contraceptive Contraceptive supply, hormone containing patch, each Contraceptive supply, hormone containing vaginal ring, each Levonorgestrel (contraceptive) implant system, including implants and supplies (Implanon) Etonogestrel (contraceptive) implant system, including implant and supplies Insertion of levonogestrel -releasing intrauterine system implants and supplies Counseling for Chemoprevention of Breast Cancer Family history of malignant neoplasm of the breast Family history of malignant neoplasm of the ovary Must have HPHC Rx Coverage to have prescription contraception covered in full. Must have HPHC Rx Coverage to have prescription contraception covered in full. Covered when billed with the listed ICD-9/10 dx codes. Harvard Pilgrim Health Care Provider Manual B.27 January 2016

12 Family history of malignant neoplasm of breast Family history of malignant neoplasm of ovary Counseling to Prevent Tobacco Use and Tobacco-Caused Disease 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 Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 10 minutes Dental Caries Prevention of Dental Caries in Preschool Children Coding Description Comments Fluoride Varnish Preventive visits and Evaluation & Management (EM) services. Coding Description Comments Application of topical fluoride varnish by a physician or other qualified health care professional Depression Major Depressive Disorder in Children, Adolescents and Adults Age 6 months through 11 years. Screening for depression, in primary care settings, includes E&M visits and Screening for depression Screening for depression, in primary care settings, includes E&M visits and Encounter for screening for other disorder Diabetes Mellitus Screening (Type 2 Diabetes) Fam hx-diabetes mellitus Screening examination; diabetes mellitus Family history of diabetes mellitus Z13.1 Encounter for screening for diabetes mellitus Harvard Pilgrim Health Care Provider Manual B.28 January 2016

13 Gonorrhea Screening Glucose; quantitative, blood (except reagent strip) Glucose; blood, reagent strip Glucose; post glucose dose (includes glucose) Glucose; tolerance test (GTT), 3 specimens (includes glucose) Glucose; tolerance test, each additional beyond 3 specimens Hemoglobin; glycosylated (A1C) Covered when billed with the listed ICD-9/10 dx codes. Female Z11.3 Encounter for screening for infections with a predominantly sexual mode of transmission Female gonorrhoeae, direct probe technique. gonorrhoeae, amplified probe technique. gonorrhoeae, quantification. Infectious agent antigen detection by immunoassay with direct optical observation; Neisseria gonorrhoeae. Hepatitis B Virus Infection Screening High Blood Pressure Screening Hepatitis B core antibody (HBcAB); Total Hepatitis B surface antibody (HBsAb). nique, qualitative or semiquantitative, multiple step method; hepatitis B surface antigen (HBsAg). nique, qualitative or semiquantitative, multiple step method; hepatitis virus, direct probe technique. virus, amplified probe technique. virus, quantification. Covered when billed with the listed ICD-9/10 dx codes. ventive, regardless of diagnosis. Description and over (see comment). Comments Included in the payment for a preventive care visit. Harvard Pilgrim Health Care Provider Manual B.29 January 2016

14 Human Immunodeficiency Virus (HIV) Screening for Adolescents and Adults Immunization - probe technique. fied probe technique. quantification. probe technique. fied probe technique. quantification. technique, qualitative or semi-quantitative, multiple-step method, technique, qualitative or semi-quantitative, multiple-step method, Infectious agent antigen detection by rapid antibody test of oral tive service when appropriately coded. tive service when appropriately coded after all of the following conditions are satisfied: - CPT/ HCPCS Description administration, with counseling by physician or other qualified health care administration, with counseling by physician or other qualified health care addition to code for primary procedure). taneous, intradermal, subcutaneous, or intramuscular injections) when the taneous, intradermal, subcutaneous, or intramuscular injections) when the for primary procedure). Comments Preventive regardless of dx. Harvard Pilgrim Health Care Provider Manual B.30 January 2016

15 CPT/ HCPCS Description nasal or oral routes of administration) when the physician counsels the per day. nasal or oral routes of administration) when the physician counsels the procedure). counseling when performed. cutaneous, or intramuscular injections); 1 vaccine (single or combination taneous, or intramuscular injections); each additional vaccine (single or mary procedure). to code for primary procedure). Hepatitis A vaccine, adult, for intramuscular use. muscular use. muscular use. Hepatitis A and hepatitis B vaccine (HepA-HepB), adult dosage, for intramuscular use. for intramuscular use. only, intramuscular use. ule), for intramuscular use. for intramuscular use. dose schedule, for intramuscular use. ule, for intramuscular use. individuals 3 years and older, for intramuscular use. months of age, for intramuscular use. years of age and older, for intramuscular use. Comments Harvard Pilgrim Health Care Provider Manual B.31 January 2016

16 CPT/ HCPCS Description and antibiotic free, for intramuscular use. nicity via increased antigen content, for intramuscular use. free, for intramuscular use. intramuscular use. lar use. Pneumococcal conjugate vaccine, 13 valent, for intramuscular use. Rotavirus vaccine, pentavalent, 3 dose schedule, live, for oral use. Rotavirus vaccine, human, attenuated, 2 dose schedule, live, for oral use. - years of age, for intramuscular use. - intramuscular use. intramuscular use. - Tetanus toxoid adsorbed, for intramuscular use. Mumps virus vaccine, live, for subcutaneous use. Measles virus vaccine, live, for subcutaneous use. Rubella virus vaccine, live, for subcutaneous use. Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use. Measles and rubella virus vaccine, live, for subcutaneous use. neous use. use. Tetanus and diphtheria toxoids (Tc) absorbed, preservative free, when Tetanus, diphtheria toxoids and acellular pertussis vaccine (TdaP), when Tetanus and diphtheria toxoids (Td) adsorbed when administered to indi- Comments Harvard Pilgrim Health Care Provider Manual B.32 January 2016

17 CPT/ HCPCS Description - - Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use. Meningococcal polysaccharide vaccine (any group(s)), for subcutaneous use. lent), for intramuscular use. Zoster (shingles) vaccine, live, for subcutaneous injection Note: coverage Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use. Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use. intramuscular use. Hepatitis B vaccine, adult dosage, for intramuscular use. schedule), for intramuscular use. cular use. Administration of pneumococcal vaccine. G0010 Administration of Hepatitis B. Comments Lung Screening Computed tomography, thorax; without contrast material. Covered when billed with the following ICD-9 diagnoses: nant neoplasm condition Covered when billed with the following ICD-10 diagnoses: Z12.2 Encounter for screening for malignant neoplasm of respiratory organs tine dependence unspecified Harvard Pilgrim Health Care Provider Manual B.33 January 2016

18 Mammography Screening G0202 Computer aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for images; screening mammography (List separately in addition to code for primary procedure). Screening mammography, bilateral (two view film study of each breast). Screening mammography producing direct digital image, bilateral, all views. Screening indicated in procedure code: not by diagnosis or frequency. Newborn Screenings Hearing Screening Encounter for health supervision and care of foundling Care of healthy child nec Routine infant or child health check Encounter for hearing examination following failed hearing screening Z Encounter for health supervision and care of foundling Encounter for health supervision and care of other healthy infant and child Encounter for routine child health examination with abnormal Encounter for routine child health examination without abnormal Z Encounter for hearing examination following failed hearing screening regardless of dx, primary. regardless of dx, primary. Hypothyroidism Screening Screening Test, pure tone, air only (Also payable under preventive benefit for children and adults as per the Certificate of Coverage). testing of the central nervous system; comprehensive. testing of the central nervous system; limited. Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products). Evoked otoacoustic emissions; comprehensive or diagnostic evaluation sions at multiple levels and frequencies). Hearing screening. Covered when billed with the listed ICD-9/10 dx codes. Thyroxine; requiring elution (e.g., neonatal). Thyroid stimulating hormone Covered when billed with a preventive (dx code). Harvard Pilgrim Health Care Provider Manual B.34 January 2016

19 Phenylketonuria Screening Covered when billed with a preventive Thyroid stimulating hormone (TSH) (dx code). Sickle Cell Screening Screening examination; sickle-cell disease or trait Z13.0 Encounter for screening for diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism Hemoglobin fractionation and quantitation; electrophoresis (e.g., A2, Hemoglobin fractionation and quantitation; chromatography (e.g., Hemoglobin; F (fetal), chemical Hemoglobin; F (fetal), qualitative Hemoglobin; plasma Sickle cell screen Obesity Screening for Children, Adolescents and Adults Routine infant or child health check Screening examination; obesity Encounter for routine child health examination without abnormal Encounter for general adult medical examination without abnormal Encounter for screening for other disorder Medical nutritional counseling ICD-9/10 dx codes. Covered when billed with an E&M service and billed with the listed ICD-9/10 dx codes. Osteoporosis Screening Family history of osteoporosis Special screening for osteoporosis Harvard Pilgrim Health Care Provider Manual B.35 January 2016

20 Family history of osteoporosis Encounter for screening for osteoporosis G0130 Ultrasound bone density measurement and interpretation, peripheral site(s), any method. more sites; axial skeleton (e.g., hips, pelvis, spine). more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel). more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel). Pharmacy U.S. Preventive Services Task Force A & B Recommendation Medications Covered when billed with the listed ICD-9/10 dx codes. Harvard Pilgrim Health Care has included certain categories of medications in the preventive services coverage based on recommendations from the U.S. Preventive Services Task Force. These preventive medications are covered under the Patient Protection and Affordable Care Act at no cost ($0 copayment) to members when prescribed by a licensed provider and filled at a network pharmacy. Coverage limitations such as age and gender rules apply, see Special Coverage Considerations (in table) for details below. This coverage does not apply to members of grandfathered plans. Note: Preventive over-the-counter (OTC) medications are covered in full when prescribed by a licensed provider and dispensed at a pharmacy pursuant to a prescription. Medication Applies to: Special Coverage Considerations Aspirin OTC generic only Fluoride drops & tablets Rx brands and generics Covered in full for preschool children age 6 months Prescription smoking cessation products Rx brands and generics Covered in full. Quantity limitations may apply. OTC brands and generics Breast cancer medications Rx brands and generics Covered in full for member who are at increased risk for breast cancer and at low risk for adverse medication effects. procedure Rx only prep kits are not covered. Rh Incompatibility Screening Obstetric panel Routine Infant or Child Health Check Routine infant or child health check Encounter for routine child health examination without abnormal Covered with diagnosis of pregnancy. Harvard Pilgrim Health Care Provider Manual B.36 January 2016

21 Routine infant or child health check Encounter for routine child health examination without abnormal Lead Screening Early Language Milestone Screen), with interpretation and report. Routine infant or child health check Personal history of contact with and (suspected) exposure to lead High risk children. Screen-contamination NEC Encounter for routine child health examination without abnormal Contact with and (suspected) exposure to lead High risk children. Encounter for screening for disorder due to exposure to contaminants Lead High risk children. Tuberculin Test Routine infant or child health check Screening examination for pulmonary tuberculosis High risk children. Encounter for health supervision and care of foundling Encounter for health supervision and care of other healthy infant and child Encounter for routine child health examination without abnormal Primary care setting, preventive with the listed ICD-9/10 dx codes. High risk children. Lead Children at risk. Harvard Pilgrim Health Care Provider Manual B.37 January 2016

22 Routine infant or child health check Encounter for health supervision and care of foundling Encounter for health supervision and care of other healthy infant and child Encounter for routine child health examination without abnormal Primary care settings, not specialists visits and is not under routine annual Screening test of visual acuity, quantitative, bilateral eye exam. Rubella Screening by History of Vaccination or by Serology Screening examination for rubella Female Encounter for routine child health examination without abnormal Female Encounter for screening for other viral diseases Female Antibody; rubella ICD-9/10 dx codes. Syphilis Screening The following is covered when billed with a diagnosis for pregnancy or screening for venereal diseases transmitted diseases Screening for sexually transmitted diseases NOS Unspecified bacterial and spirochetal disease Encounter for supervision of normal first pregnancy, unspecified trimester Encounter for supervision of other normal pregnancy, unspecified trimester Z33.1 Pregnant State, incidental Supervision of pregnancy with history of infertility, unspecified trimester Supervision of pregnancy with history of ectopic or molar pregnancy, unspecified trimester Supervision of pregnancy with other poor reproductive or obstetric history, first trimester Excludes: Special screening for nonbacterial sexually transmitted diseases Excludes: Special screening for nonbacterial sexually transmitted diseases Harvard Pilgrim Health Care Provider Manual B.38 January 2016

23 Supervision of pregnancy with grand multiparity, unspecified trimester Supervision of pregnancy with history of pre-term labor, first trimester Supervision of pregnancy with history of ectopic or molar pregnancy, unspecified trimester Supervision of pregnancy with other poor reproductive or obstetric history, first trimester Supervision of pregnancy with insufficient antenatal care, unspecified trimester Supervision of elderly primigravida, unspecified trimester Supervision of elderly multigravida, unspecified trimester Supervision of young primigravida, unspecified trimester Supervision of young multigravida, unspecified trimester Supervision of pregnancy resulting from assisted reproductive technology, unspecified trimester Supervision of pregnancy with history of in utero procedure during previous pregnancy, unspecified trimester Pregnancy with inconclusive fetal viability, not applicable or unspecified Supervision of other high risk pregnancies, unspecified trimester Supervision of high risk pregnancy, unspecified, unspecified trimester Encounter for gynecological examination (general) (routine) with abnormal Encounter for gynecological examination (general) (routine) without abnormal Z11.2 Encounter for screening for other bacterial diseases Z11.3 Encounter for screening for infections with a predominantly sexual mode of transmission Encounter for screening for other infectious and parasitic diseases Encounter for screening for other infectious and parasitic diseases Voluntary Sterilization ART) Syphilis test, non-treponemal antibody; quantitative Pharmacy Pharmacy Solutions Pharmacy-Other Medical Supplies Anesthesia Covered when billed with the listed ICD-9/10 dx codes. Covered when billed with Recovery Room Covered when billed with Anesthesia-tubal ligation Harvard Pilgrim Health Care Provider Manual B.39 January 2016

24 J3010 J0330 J1100 J1630 J2001 Wellness Examinations 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 tion (separate procedure) 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) 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) Salpingectomy, complete or partial, unilateral or bilateral (separate procedure) Injection, heparin sodium, per 1000 units Injection, morphine sulfate, up to 10 mg Injection, ondansetron HCl, per 1 mg Ringers lactate infusion, up to 1,000 cc Injection, fentanyl citrate, 0.1 mg Injection, metoclopramide HCl, up to 10 mg Injection, succinylcholine chloride, up to 20 mg Injection, dexamethasone sodium phosphate, 1 mg Injection, droperidol and fentanyl citrate, up to 2 ml ampule Injection, lidocaine HCl for intravenous infusion, 10 mg Normal Saline Solution Applies to female only. Covered when billed with Description Well baby, well child, well adult, well woman Comments Resources Federal Health Care Reform Harvard Pilgrim Health Care Provider Manual B.40 January 2016

25 services to coding grid diabetes screening Harvard Pilgrim Health Care Provider Manual B.41 January 2016