Strict Covered Limitations that may be used by some ASO groups. covered in full for Men only, age 65-75

Transcription

1 Recommendation Adult Aortic Aneurysm Screening (one time age if ever smoked) Alcohol & Drug Misuse Screening and Behavioral Counseling Intervention Aspirin for the Prevention of Cardiovascular Disease Men Aspirin for the Prevention of Cardiovascular Disease Women Asymptomatic Bacteriuria in Adults, Screening covered in full for adults >50 covered in full when provided by PCP or OB/GYN covered in full for men covered In full for women covered in full for pregnant women covered in full for Men only, age covered in full when provided by PCP or OB/GYN covered in full for men covered In full for women covered in full for pregnant women ASO. Based on the G , 99409, G0396, G0397. G0442, G0443 for 2012 Will be billed with NDC to pharmacy (script required) but paid as medical benefit Will be billed with NDC to pharmacy (script required) but paid as medical benefit 87081and and with diagnosis 4158F, 4320F, 3016F 4011F, G8598, G F, G8598, G8599 V81.5, V22.xx, V23.xx, V28.9x, 651.XX, Breast Cancer Screening (Biennial 50-74) covered in full for women > 35 unless med nec: 1 baseline age 35-39; annual age 40+; additionally: 1 mammogram per year for individual, any age, having a prior history of breast cancer or a 1st degree relative with prior history of breast cancer covered in full for women > 40 for ASO; covered in full for women > 35 for DP/HNY 77051, 77055, 70556, G0204, G0206 with dx edits, 77052, 77057, G0202 no dx needed 3014F V76.11, V76.12 Page 1 of 19

2 7 8 8w Recommendation Breast and Ovarian Cancer Susceptibility, Genetic Risk Assessment and BRCA Mutation Testing Based on Family Risk Factors Breastfeeding, Primary Care Interventions to Promote Breastfeeding support, supplies and counseling ASO. Based on the 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255, 96040, S0265 with dx edits S9443 (code for classes) E0603 purchase or rental, E0604 RR for pump rental., A4281, A4282, A4283, A4284, A4285, A4286 for supplies. V26.33, V84.01, V84.02, V16.3, V Cervical Cancer Screening if Sexually Active 1 per year covered in full 1 per year covered in full 88141, 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88154,88155, 88164, 88165, 88166, 88167, 88174, with dx edits, G0101, G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001 no dx edits needed V76.2, V72.3x, V76.2, V72.31, 9w Human papillomavirus testing >29 every 3 years covered in full >29 every 3 years covered in full 87620, 87621, with Dx edits V73.81, V76.2, V72.31, V76.47 Page 2 of 19

3 10 11 Recommendation Chlamydial Infection, Screening; non pregnant women and pregnant women Colorectal Cancer Screening (Beginning at 50 and continuing to 75) Fecal occult blood testing: annual Sigmoidoscopy: every 5 years Colonoscopy: every 10 years ASO. Based on the covered in full for women covered in full for women covered in full for adults >50 covered in full for adults age , 87320, 87800, 87801, with dx edits, 87490, 87491, no dx needed 82270, 82274, 88305, G0328, S0601, 45330, 45331, 45332, 45333, 45334, 45335, 45337, 45338, 45339, 45340, 45341, 45342, 45345, 44388, 44389, 44390, 44391, 44392, 44393, 44394, 44397, 45355, 45378, 45379, 45380, 45381, 45382, 45383, 45384, 45385, 45386, 45387, 45391, 45392, with dx edits; F 651.xx, V01.6, V15.85, V22.xx, V23.xx, V28.8, V28.9, V69.2, V72.3, V76.2, V73.88, V73.98, V74.5 V76.41, V76.50, V76.51, V76.52 G0104, G0105, G0121 is always screening by definition. No dx needed. 12 Congenital Hypothyroidism Screening (Newborns) covered in full for children less than one year of age covered in full for children less than one year of age 84436, 84437,84439, 84443, 84479, S3620 with dx edits V77.0 Page 3 of 19

4 Recommendation Dental Caries in Preschool Children, Prevention (prescribe oral fluoride if deficient in water) Depression (Adults) Screening (When staff-assisted depression care supports are in place) Major Depressive Disorders in Adolescents, Screening Diet, Behavioral Counseling in Primary Care for Adults with Hyperlipidemia and Other Risk Factors covered in full for children 6 mo-5 yrs covered in full for children 6 mo-5 yrs ASO. Based on the covered in full for all adults covered in full for adults > Gonorrhea Screening covered in full for women covered in full for women 17 Gonorrhea, Prophylactic Eye Medication, (Newborns) 18 Hearing Loss in Newborns, Screening covered in full for children < 1 covered in full for children < 1 Will be billed with NDC to pharmacy (script required) but paid as medical benefit Generally part of visit and not coded separately. G0444 eff , 97803, 97804, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, S9452, S9470, G0270, G0271, G0108, G0109, S9140, S9141, S9455, S9460, S9465, S9449 with dx edits G0446 for , 87591, no dx needed, 87800, 87801, with dx edits Done at delivery; part of inpatient stay 92586, with dx edits; F, 3351F, 3352F, 3353F, 3354F with visit 3511F, 4293F V65.3 along with any other dx that does not start with V. 651.xx, V01.6, V15.85, V22.xx, V23.xx, V28.8, V28.9, V69.2, V72.3, V76.2, V74.5 V72.19 Page 4 of 19

5 Recommendation ASO. Based on the 19 Hepatitis B Virus Infection, Screening covered in full for women covered in full for women and no dx needed; 86704, 86705, 86706, 86707, 87341, 87350, 87515, 87516, with dx edits 3216F, 3513F V22.xx, V23.xx, V28.8, V28.9, 651.xx 20 High Blood Pressure Screening (18 and older) Generally part of visit and not coded separately. 2000F, 3074F, 3075F, 3077F, 3078F, 3079F, G8477, G billed with E and M code 21 HIV Screening (At Risk and All Pregnant Women) G0432, G0433, G0435, 86701, 86702, no edits needed, 86689, 87390,87391, 87534, 87535, 87536, 87537, 87538, 87539, 87901, 87903, with dx edits 651.xx, V01.6, V15.85, V22.xx, V23.xx, V28.8, V28.9, V69.2, V72.3, V76.2, V74.5, V w 22 Counseling and screening for human immune-deficiency virus (HIV) Iron Deficiency Anemia, Prevention (At Risk 6 to 12 Month Old Babies) covered in full for all children 6 to 12 months covered in full for all children 6 to 12 months Screening is already covered for some women. No specific codes for counseling. Part of visit. Will be billed with NDC to pharmacy (script required) but paid as medical benefit Page 5 of 19

6 Recommendation ASO. Based on the 23 Iron Deficiency Anemia, Screening covered in full for pregnant women covered in full for pregnant women 80055, 85013, 85014, 85018, 85025, 85027, with dx edits 651.xx, V22.xx, V23.xx, V28.8, V Screening for cholesterol abnormalities 25 Obesity in Adults Screening and Intensive Counseling and Behavioral Interventions Screening and counseling for obesity: children covered in full for all ages covered in full for age > , 82465, 83700, 83701, 83704, 83718, 83721, with dx edits 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 97802, 97803, 97804, G0270, G0271, G0447, S9451, S9452, S9470, S9449 with dx edits 3011F, 3048F, 3049F, 3050F, G8593 V77.91 V77.8, V85.5x, V65.3, V Osteoporosis in Women, Screening: 65+ / 60+ If At Risk (Includes DEXA and/or bone density testing (BMD)) Covered in full for men and women covered in full for women > , 77080, 77081, 77082, 77083, 78350, 78351, 76977, G0130 with dx edits V82.81, V07.4, V Phenylketonuria, Screening Newborn 28 Rh (D) Incompatibility, Screening covered in full for pregnant women covered in full for pregnant women with dx edits, S3620 no edits needed 80055, with dx edits V77.3 V22.xx, V23.xx, V28.8, V28.9, 651.xx Page 6 of 19

7 Recommendation ASO. Based on the 29 Sexually Transmitted Infections, Counseling (at risk adolescents and adults) 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, with dx edits G0445 V65.44, V65.45, V w Counseling on sexually transmitted infections (STIs) 30 Sickle Cell Disease, Screening Newborns Syphilis Infection Screening (At Risk and All Pregnant Women) Tobacco Use and Tobacco-Caused Disease, Counseling Type 2 Diabetes Mellitus in Adults, Screening with Sustained Blood Pressure Adult women only covered in full for children < 1 adults only, age > 19 covered in full covered in full for children < 1 adults only, age > 19 covered in full No specific codes. Part of visit. Part of DRG; 83020, with dx edits, S3620 no edits needed 80055, 86592, 86593, with dx edits 99406, ; G0436, G , with dx edits 3512F 3074F, 3075F, 3077F, 3078F, 3079F, 3080F V xx, V01.6, V22.xx, V23.xx, V28.8, V28.9, V69.2, V74.5, V72.3x, V76.2 V w Screening for gestational diabetes 82950, 82951, with Dx edits V77.1, V22.xx, V23.xx Visual Impairment in Children Younger than 5 Years, Screening; Effective 1/1/11 age expanded to age 5 and younger Discuss Chemoprevention When at High Risk for Breast Cancer covered in full for children < 4 5 covered in full for children < with dx edits; applicable to ITS Home claims only since code bundles for local business Generally part of visit and not coded separately. V72.0, V80.2, , , Page 7 of 19

8 Recommendation 36 Daily Supplement of Folic Acid covered in full for all women up to age 63 covered in full for all women up to age 63 ASO. Based on the Will be billed with NDC to pharmacy (script required) but paid as medical benefit 37 PSA Testing covered in full for all men >= 30 NA - see comment below 84152, 84153, with dx edits, G0102, G0103 no edits needed V76.44, V70.0 V Routine OB/GYN Visit 39 Routine Physical and/or Counseling 39w Well woman visits - Wellness preventive care 2 exams per year (Facets will do this.) 1 exam annually covered in full (Facets will do this.) NA - see comment below Age covered in full , 99385, 99386, 99387, 99394, 99395, 99396, with dx edits, Q0091, Q0111, G0101, S0610, S0612, S0613 no edits needed 99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397, 99460, 99461, 99463, G0402, 99401, 99402, 99403, 99404, 99406, 99407, 99408, with dx edits; G0438, G0439 Same codes as already covered under existing preventive guidelines. V72.3-V72.32, V76.2, V76.47, V25.40-V25.49 Page 8 of 19

9 Recommendation ASO. Based on the 40 Routine Vision Exam 1 every 2 yrs; 1 per yr for under 14 with diagnosed refractive error covered in full. NA - see comment below 41 Well Child Visits 42 Well Child Vaccines and Vaccine Administration, Lab and Developmental Testing S0620, S0621, 92002, 92004, 92012, 92014, with dx edits Refer to Well Child Guidelines Per ACIP/AAP/ USPSTF recommendations - refer to Well Child Guidelines for vaccines , V72.0, V Adult Immunizations and Vaccine Administration adults > 19 years of age covered in full no routine immunizations covered OON adults > 19 years of age covered in full Per ACIP guidelines; 90632, 90636, 90649, 90650, 90669, 90670, 90696, 90698, 90701, 90703, 90705, 90706, 90707, 90708, 90710, 90714, 90715, 90716, 90718, 90732, 90733, 90734, 90736, 90740, 90746, 90747, 90471, 90472, 90473, 90474, G0009, G0010 Page 9 of 19

10 Recommendation ASO. Based on the 44 Flu Vaccine and Vaccine Administration covered in full for all w Lab work ordered as part of a routine physical or routine ob/gyn visit Screening and counseling for interpersonal and domestic violence Lab tests within 30 days of routine physical covered in full 90654, 90655, 90656, 90657, 90658, 90659, 90660, 90661, 90662, 90460, 90461, 90471, 90472, 90473, 90474, G0008, Q2035, Q2036, Q2037, Q2038, Q2039 No specific codes. Part of visit. DX to match that of routine physical OR V72.62 Page 10 of 19

11 Recommendation ASO. Based on the 47 w Contraceptive methods and counseling 58600, 58605, 58611, 58615, 58670, for surgical procedures , 58300, 58565, 58615, 58661, 58720, A4261, A4266, A4268 (NC), A4269 (NC), J1050, J1055 deleted 2013, J7300, J7301, J7302, J7303, J7304, J7306, J7307, S4981, S4989, S4993 (NSF) and with dx code that starts with a V. Contraceptives thru Medco 48 Screening for Hepatitis C Virus Infection in Adults age 18 and older covered in full 86803, Prevention of Falls in Community- Dwelling Older Adults; exercise or physical therapy age 65 and older covered in full 97001, 97002, 97039, 97110, 97112, 97113, 97116, 97139, 97150, 97350, G0157, G0159 Refer to codes for fall prevention tab at the end of this document. Page 11 of 19

12 Recommendation ASO. Based on the 50 Prevention of Falls in Community- Dwelling Older Adults; vitamin D age 65 and older covered in full Paid under pharmacy benefit. Rx is required. 51 Skin Cancer behavioral counseling Age 10 to 24 covered in full Generally part of visit and not coded separately. 52 Medications to reduce the risk of breast cancer (Tomoxifen and Raloxifene) Age >35 Paid under pharmacy benefit. Rx is required. Prior approval is required. Page 12 of 19

13 Corporate Standard Recommended Implementation Strategy PT visits accumulate toward PT limits Provider determines if individual is considered high risk Initial office visit and subsequent PT visits for fall prevention covered at no cost share Community-dwelling means that the individual is not in an assisted living facility, nursing home, skilled nursing facility or an inpatient at a hospital. CORPORATE STANDARD CODING FOR FALL PREVENTION RECOMMENDATION Procedure codes Code Definition PT evaluation PT re-evaluation Unlisted PT modality Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and standing activities Therapeutic procedure, 1 or more areas, each 15 minutes; aquatic therapy with therapeutic exercises Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing) Unlisted therapeutic procedure Non discript Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes G0157 Services performed by qualified physical therapist assistant in the home health or hospice setting, each 15 min G0159 Services performed by a qualified physical therapist, in the home health setting, in the establishment or delivery of a safe and effective PT maintenance program, each 15 min

14 ICD9 Diagnosis codes Code Definition V15.88 History of falls/at risk for falling Dizziness and giddiness Chronic fatigue syndrome Other malaise and fatigue Abnormality of gait Lack of coordination Other specified hypoglycemia Hypoglycemia, unspecified 280 Iron deficiency anemia secondary to blood loss (chronic) Iron deficiency anemia secondary to inadequate dietary iron intake Other specified iron deficiency anemias 281 Pernicious anemia Other vitamin B12 deficiency anemia Folate deficiency anemia Other specified megaloblastic anemias NOC Protein deficiency anemia Anemia associated with other specified nutritional deficiency 282 Hereditary spherocytosis Hereditary eliptoctyosis Anemias due to disorders of glutathione metabolism Other hemolytic anemias due to enzyme deficiency Sickle-cell thalassemia without crisis Sickle-cell thalassemia with crisis Alpha thalassemia Beta thalassemia Delta-beta thalassemia Thalassemia minor Hemoglobin E-beta thalassemia Other thalassemia

15 282.5 Sickle-cell trait Sickle-cell disease, unspecified Hb-SS disease without crisis Hb-SS disease with crisis Sickle-cell/Hb-C disease without crisis Sickle-cell/Hb-C disease with crisis Other sickle-cell disease without crisis Other sickle-cell disease with crisis Other hemoglobinopathies Other specified hereditary hemolytic anemias 283 Autoimmune hemolytic anemias Non-autoimmune hemolytic anemias, unspecified Hemolytic-uremic syndrome Other non-autoimmune hemolytic anemias Hemoglobinuria due to hemolysis from external causes Constitutional red blood cell aplasia Other constitutional aplastic anemia Antineoplastic chemotherapy induced pancytopenia Other drug-induced pancytopenia Other pancytopenia Myelophthisis Thalassemia, unspecified Red cell aplasia (acquired) (adult) (with thymoma) Other specified aplastic anemias 285 Sideroblastic anemia Acute posthemorrhagic anemia Anemia in chronic kidney disease Anemia in neoplastic disease Anemial of other chronic disease Antineoplastic chemotherapy induced anemia Other specified anemias 286 Congenital factor VIII disorder Congenital factor IX disorder

16 286.2 Congenital factor XI deficiency Congenital deficiency of other clotting factors von Willebrand's disease Acquired hemophilia Antiphospholipid antibody with hemorrhagic disorder Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors Defibrination syndrome Acquired coagulation factor deficiency Other and unspecified coagulation defects 287 Allergic purpura Qualitative platelet defects Other nonthrombocytopenic purpuras Primary thrombocytopenia, unspecified Immune thrombocytopenic purpura Evan's syndrome Congenital and hereditary thrombocytopenic purpura Other primary thrombocytopenia Posttransfusion purpura Other secondary thrombocytopenia Thrombocytopenia, unspecified Other specified hemorrhagic conditions Unspecified hemorrhagic conditions 288 Neutropenia, unspecified Congenital neutropenia Cyclic neutropenia Drug induced neutropenia Neutropenia due to infection Other neutropenia Functional disorders of polymorphonuclear neutrophils Genetic anomalies of leukoctyes Eosiniphilia Hemophagocytic syndromes

17 293 Delirium due to conditions classified elsewhere Subacute delirium 386 Meniere's disease, unspecified Active Meniere's disease, cochleovestibular Active Meniere's disease, cochlear Active Meniere's disease, vestibular Inactive Meniere's disease Peripheral vertigo, unspecified Benign paroxysmal positional vertigo Vestibular neuronitis Other peripheral vertigo Vertigo of central origin Labyrinthitis, unspecified Serous labyrinthitis Circumscribed labyrinthitis Suppurative labyrinthitis Viral labyrinthitis Labyrinthine fistula, unspecified Round window fistula Oval window fistula Semicircular canal fistula Labyrinthine fistula of combined sites Labyrinthine dysfunction, unspecified Hyperactive labyrinth, unilateral Hyperactive labyrinth, bilateral Hypoactive labyrinth, unilateral Hypoactive labyrinth, bilateral Loss of labyrinthine reactivity, unilateral Loss of labyrinthine reactivity, bilateral Other disorders of labyrinth Unspecified verginous syndromes and labyrinthine disorders 427 Paroxysmal supraventricular tachycardia Paroxysmal ventricular tachycardia

18 427.2 Paroxysmal tachycardia, unspecified Atrial fibrillation Atrial flutter Ventricular fibrillation Ventricular flutter Cardiac arrest Premature beats, unspecified Supraventricular premature beats Other premature beats Sinoatrial node dysfunction Other specified cardiac dysrhythmia Cardiac dysrhythmia, unspecified 458 Orthostatic hypotension Chronic hypotension Hypotension of hemodialysis Other iatrogenic hypotension Other specified hypotension Hypotension, unspecified Difficulty in walking, pelvic region and thigh Difficulty in walking, lower leg Difficulty in walking, ankle and foot Difficulty in walking, other specified sites Difficulty in walking, multiple sites 733 Osteoporosis, unspecified Senile osteoporosis Idiopathic osteoporosis Disuse osteoporosis Other osteoporosis Pathologic fracture, unspecified site Pathologic fracture of vertebrae Pathologic fracture of neck of femur Pathologic fracture of other specified part of femur Pathologic fracture of tibia or fibula

19 780.2 Syncope and collapse Nonspecific low blood pressure reading