NOTE: Please append modifier 33 when indicated. If modifier 33 is not appended, regular plan benefits will be applied.
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1 Policy name: Preventive Health Guidelines - Men 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 Abdominal Aortic Aneurysm G0389 Ultrasound B-scan and/or real time with image documentation; for adominal aortic aneurysm (AAA) screening V81.2 Z13.6 Colorectal Cancer Yes V16.0 V18.51 V18.9 V76.41 V76.51 Z12.11 Z12.12 Z80.0 Z83.71 Z84.81 G0104 Colorectal cancer screening; flexible sigmoidoscopy G0105 Colorectal cancer screening; colonoscopy on individual at high risk G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk 450 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 459 with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique with dilation by balloon, 1 or more strictures Colonoscopy, rigid or flexible, transabdominal via colotomy, single or multiple 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) Updated on 12/19/2014 Preventive Health - Men - Coding Guidelines Page 1
2 Colorectal Cancer (con't) 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 ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique V16.0 V18.51 V18.9 V76.41 V76.51 Z12.11 Z12.12 Z80.0 Z83.71 Z 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 transendoscopic stent placement (includes predilation) with endoscopic ultrasound examination with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s) G0328 Colorectal cancer screening; fecal occult blood test, immunoassay, 1-3 simultaneous determinations 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 Type 2 Diabetes Mellitus High Blood Pressure Glucose; quantitative, blood (except reagent strip) Yes V77.1 Z Hemoglobin; glycosylated (A1C) Yes V81.1 Z01.30 Z01.31 Z13.6 HIV Antibody; HTLV or HIV antibody, confirmatory test (eg, Western Blot) V73.89 Z11.4 Z Antibody; HIV Antibody; HIV Antibody; HIV-1 and HIV-2, single result Updated on 12/19/2014 Preventive Health - Men - Coding Guidelines Page 2
3 HIV (con't) (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 V73.89 Z11.4 Z (eff 1/1/2013) Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; HIV (eff 1/1/2013) Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; HIV-2 G0432 G04 Infectious agent antibody detection by enzyme immunoassay (EIA) technique, HIV-1 and/or HIV-2, screening Infectious agent antibody detection by enzyme-linked immunosorbent assay (ELISA) technique, HIV-1 and/or HIV-2, screening G0435 Infectious agent antigen detection by rapid antibody test of oral mucosa transudate, HIV-1 or HIV-2, screening Lipid Disorders Lipid panel V77.91 Z Cholesterol, serum or whole blood, total Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) Syphilis Syphilis test, non-treponemal antibody; qualitative (e.g., VDRL, RPR, ART) Antibody; Treponema pallidum V69.2 V74.5 Z11.3 Z72.51 Z72.52 Z72.53 Screening for hepatitis C virus (HCV) G0472 Hepatitis C antibody screening for individual at high risk and other covered indication(s) V73.89 V01.79 Z11.59 Z20.5 Z Screening for hepatitis B virus (HBV) Aspirin for the prevention of Cardiovascular disease (CVD) Infectious agent antigen detection by enzyme immunoassay technique, V73.89 Z11.59 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) Hepatitis B core antibody (HBcAb); total Hepatitis B core antibody (HBcAb); IgM antibody Hepatitis B surface antibody (HBsAb) Covered through HMSA's Pharmacy Benefit Manager with prescription Updated on 12/19/2014 Preventive Health - Men - Coding Guidelines Page 3
4 Alcohol Misuse Yes V65.42 V 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. Depression Yes V79.0 Z Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale, with scoring and documentation, per standardized instrument Tobacco Use and Tobacco Caused Disease Yes V 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 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 Updated on 12/19/2014 Preventive Health - Men - Coding Guidelines Page 4
5 Obesity Yes V70.1 V Z04.6 Z13.1 E66.01-E66.1 E66.8-E reduction intervention(s) provided to an individual or individuals in a group setting (separate procedure). Differences in codes are timebased Medical nutrition therapy; initial assessment and intervention, individual, face-to-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 Sexually Transmitted Infections (STI) Nutritional counseling, dietitian visit Medical nutrition therapy; initial assessment and intervention, individual, face-to-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 S9452 S Nutrition classes, nonphysician provider, per session Nutritional counseling, dietitian visit reduction intervention(s) provided to an individual or individuals in a group setting (separate procedure). Differences in codes are timebased. Yes V65.3 with one of the following additional diagnoses: Yes V15.89 V65.44 V65.45 V69.2 Z71.3 with one of the following 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 E78.0-E78.70 E78.79-E78.9 E88.1-E88.2 E88.89 Z70.0-Z70.1 Z71.7 Z71.89 Z72.51-Z72.53 Z77.21 Z77.9 Z91.89 Updated on 12/19/2014 Preventive Health - Men - Coding Guidelines Page 5
6 Prevention of falls Yes V65.43 Z91.81 Vitamin D supplementation for the prevention of falls Covered through HMSA's Pharmacy Benefit Manager with prescription Skin cancer Yes various Z12.83 Z91.89 Lung Cancer S8032 Low-dose computed tomography for lung cancer screening. V76.0 Z12.2 Updated on 12/19/2014 Preventive Health - Men - Coding Guidelines Page 6
NOTE: Please append modifier 33 when indicated. If modifier 33 is not appended, regular plan benefits will be applied.
Policy name: Preventive Health Guidelines - Men The following chart contains procedure and diagnosis code combinations that identify services covered under HMSA's Preventive Health s policy. * For professional
NOTE: Please append modifier 33 when indicated. If modifier 33 is not appended, regular plan benefits will be applied.
Policy name: Health Guidelines - Men This policy applies only to non-grandfathered plans as defined in the Affordable Care Act section 1251. The following chart contains procedure, diagnosis and modifier
OBSOLETE. NOTE: Please append modifier 33 when indicated. If modifier 33 is not appended, regular plan benefits will be applied.
This document is obsolete. For current content, please see Preventive Health Guidelines - Women. Policy name: Preventive Health Guidelines - Women The following chart contains procedure and diagnosis code
NOTE: Please append modifier 33 when indicated. If modifier 33 is not appended, regular plan benefits will be applied.
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
Procedure Description Modifier 33 Required? Screening test of visual acuity, quantitative, bilateral No Z Z00.129
Policy Name: Preventive Health Guidelines - Newborns and Children This policy applies only to non-grandfathered plans as defined in the Affordable Care Act section 1251. The following chart contains procedure,
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45378-53 45380 45381 45382 45384 45385 48388 45390 ; Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon
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