Procedure Description Modifier 33 Required? Screening test of visual acuity, quantitative, bilateral No Z Z00.129

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1 Policy Name: Preventive Health Guidelines - Newborns and Children This policy applies only to non-grandfathered plans as defined in the Affordable Care Act section The following chart contains procedure, diagnosis and modifier code combinations that identify services covered under HMSA's Preventive Health Services policy. * For professional claims, the applicable ICD-9 or 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 33 when indicated. If modifier 33 is not appended, regular plan benefits will be applied. Preventive Service CPT or Bright Futures Recommendations Sensory Screening Vision Screening test of visual acuity, quantitative, bilateral Z Sensory Screening Hearing Screening test, pure tone, air only Pure tone audiometry (threshold); air only Tympanometry (impedance testing) Evoked otoacoustic emissions, screening (qualitative measurement of distortion product or transient evoked otoacoustic emissions), automated analysis Z Z38.00 Z38.01 Z38.1 Z38.2 Z38.30 Z38.31 Z38.4 Z38.5 Z Z38.66 Z38.68 Z38.69 Z38.7 Z38.8 Z01.10 Developmental Screening Autism Screening Alcohol and Drug Use Assessment Developmental screening (eg, developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument G0451 Development testing, with interpretation and report, per standardized instrument form Developmental screening (eg, developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument G0451 Development testing, with interpretation and report, per standardized instrument form Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes Z Z Z71.41 Z71.51 Updated on 08/21/2017 Preventive Health - Newborns and Children - Coding Guidelines Page 1

2 Alcohol and Drug Use Assessment (con't) Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; greater than 30 minutes Administration of patient; focused heath risk assessment instrument (eg, health hazard appraisal) with scoring and documentation, per standardized instrument Z71.41 Z71.51 Depression Screening Developmental screening (eg, developmental milestone survey, speech Z13.89 and language delay screen), with scoring and documentation, per standardized instrument Administration of patient; focused heath risk assessment instrument (eg, health hazard appraisal) with scoring and documentation, per standardized instrument Brief emotional/behavioral assessment (eg, depression inventory, attentiondeficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument Physical Examination Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant Initial care, per day, for evaluation and management of normal newborn infant seen in other than hospital or birthing center Subsequent hospital care, per day, for evaluation and management of normal newborn Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant admitted and discharged on the same date Hospital discharge day management; 30 minutes or less Z38.00 Z38.01 Z38.1 Z38.2 Z38.30 Z38.31 Z38.4 Z38.5 Z Z38.66 Z38.68 Z38.69 Z38.7 Z38.8 P00.3 P00.89 P 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 (Differences in codes are age based) Z00.00 Z00.01 Z Z Z 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 (Differences in codes are age based) Newborn Metabolic/ Hemoglobin Screening Collection of venous blood by venipuncture Yes 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) Z13.0 Z13.21 Z Z Hemoglobin (Hgb) Updated on 08/21/2017 Preventive Health - Newborns and Children - Coding Guidelines Page 2

3 Hematocrit or Hemoglobin Collection of venous blood by venipuncture Yes Z Hematocrit (Hct) Hemoglobin (Hgb) Lead Screening Collection of venous blood by venipuncture Yes Z Lead Tuberculin Test Skin test; tuberculosis, intradermal Z11.1 Dyslipidemia Screening Collection of venous blood by venipuncture Yes Z Lipid panel Cholesterol, serum or whole blood, total Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) Triglycerides STI Screening Collection of venous blood by venipuncture Yes Antibody; Chlamydia Antibody; Chlamydia, IgM Antibody; HIV Antibody; HIV-1 and HIV-2, single result Culture, presumptive, pathogenic organisms, screening only; Culture, chlamydia, any source Smear, primary source with interpretation; wet mount for infectious agents (eg, saline, India ink, KOH preps) Infectious agent antigen detection by immunofluorescent technique; Chlamydia trachomatis Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; Chlamydia trachomatis Z Z01.84 Z01.89 Z11.3 Z11.8 Z Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, direct probe technique Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, quantification Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, direct probe technique Infectious agent detection by nucleic acid (DNA or RNA); 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 Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified probe(s) technique Updated on 08/21/2017 Preventive Health - Newborns and Children - Coding Guidelines Page 3

4 STI Screening con't Infectious agent antigen detection by immunoassay with direct optical observation; Chlamydia trachomatis Infectious agent antigen detection by immunoassay with direct optical observation; Neisseria gonorrhoeae Z Z01.84 Z01.89 Z11.3 Z11.8 Z11.9 Cervical Dysplasia Screening Cytopathology, cervical or vaginal screening by various methods and to report physician interpretation services 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, reports by technician under physician supervision; or requiring interpretation by physician USPSTF A and B recommendations Congenital Collection of venous blood by venipuncture Yes Z Thyroxine; total Thyroxine; requiring elution (eg, neonatal) Thyroxine; free Thyroid stimulating hormone (TSH) Phenylketonuria (PKU) Collection of venous blood by venipuncture Yes Z Phenylalanine (PKU), blood Sickle cell anemia Collection of venous blood by venipuncture Yes Z13.0 Screening for hepatitis B virus (HBV) Hemoglobin fractionation and quantitation; electrophoresis (e.g., A2, S, C, and/or F) Hemoglobin fractionation and quantitation; chromatography (eg, A2, S, C, and/or F) Collection of venous blood by venipuncture Yes Z Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; hepatitis B surface antigen (HBsAg) Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; hepatitis B surface antigen (HBsAg) Hepatitis B core antibody (HBcAb); total Hepatitis B core antibody (HBcAb); IgM antibody Hepatitis B surface antibody (HBsAb) Updated on 08/21/2017 Preventive Health - Newborns and Children - Coding Guidelines Page 4

5 Prevention of dental caries Iron supplementation Covered through HMSA's Pharmacy Benefit Manager with prescription Application of topical fluoride varnish by a physician or other qualified various Covered through HMSA's Pharmacy Benefit Manager with prescription Obesity Office or other outpatient visit for the evaluation and management of a new or established patient, which requires these 3 key components: A problem focused history; a problem focused examination; a straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Differences in codes are time-based. Yes Z04.6 Z13.1 E66.01-E66.1 E66.8-E Counseling. Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual or individuals in a group setting (separate procedure). Differences in codes are time-based Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes Medical nutrition therapy; re-assessment and intervention, individual, faceto-face with the patient, each 15 minutes Medical nutrition therapy; group (2 or more individual(s)), each 30 minutes S9470 Skin cancer Nutritional counseling, dietitian visit Office or other outpatient visit for the evaluation and management of a new or established patient, which requires these 3 key components: A problem focused history; a problem focused examination; a straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Differences in codes are time-based. Yes Z12.83 Z Counseling. Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure). Differences in codes are time-based. Tobacco Use and Tobacco Caused Disease Office or other outpatient visit for the evaluation and management of a new or established patient, which requires these 3 key components: A problem focused history; a problem focused examination; a straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Differences in codes are time-based. Yes Z71.6 Z F F F F F F F F Counseling. Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure). Differences in codes are time-based. Updated on 08/21/2017 Preventive Health - Newborns and Children - Coding Guidelines Page 5

6 Tobacco Use and Tobacco Caused Disease (con't) 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 G0436 G0437 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 Syphilis Collection of venous blood by venipuncture Yes Syphilis test, non-treponemal antibody; qualitative (eg, VDRL, RPR, ART) Antibody; Treponema pallidum Z71.6 Z F F F F F F F F Z11.3 Z72.51 Z72.52 Z72.53 Updated on 08/21/2017 Preventive Health - Newborns and Children - Coding Guidelines Page 6