An Independent Licensee of the Blue Cross and Blue Shield Association Preventive Care Services The following is a list of preventive services (HCP rider) along with the diagnoses and procedure codes that Blue Cross and Blue Shield of Alabama has determined to meet and in some situations exceed the requirements and recommendations issued by the Affordable Care Act (healthcare reform). Blue represents coding updates. Description Code Notes Abdominal Aortic Aneurysm, Screening Males only (with any history of smoking) Ages 65-75 years One in a lifetime Alcohol Misuse Screening and Behavioral Counseling Interventions (as needed) Aspirin for the Prevention of Cardiovascular Disease men ages 45-79 years women ages 55-79 years Once every 5 calendar years Asymptomatic Bacteriuria in Pregnant Women, Screening G0389 with diagnosis V81.2, V15.82, or 305.1 99408 with diagnosis V79.1, or 305.00-305.03 1/1/12 add G0442 and G0443 6/30/12 cancel 99408 99401, 99386, 99387, 99396, or 99397 with diagnosis V65.8 87081, 87084, 87086, or 87088 with diagnosis V22.0 - V23.0, 640.00-659.93, V91.00-V91.03, V91.09-V91.12, V91.19-V91.22, V91.29, V91.90-V91.92, V91.99, or V81.5 age restriction set up at 18-99 years age restriction set up at 45-99 years and 55-99 years Breast and Ovarian Cancer Susceptibility, Genetic Risk Assessment and BRCA Mutation Testing One session in a lifetime Breastfeeding, Behavioral Interventions to Promote Twice per calendar year 96040, or 99401-99404 with diagnosis V16.3, V16.41, V26.33, or v84.01 99401 must have modifier TH and diagnosis V22.0- V23.9 or V24.1 combined with chemo prevention of breast cancer *Also see Women s Preventive section at the bottom of this document
Cervical Cancer, Screening (PAP Smear) also known as Cervical Dysplasia Screening No age limitations Chemoprevention of breast cancer One in a lifetime Chlamydia Infection, Screening Females ages 15-24 years Routine Cholesterol (Lipid Disorders in Adults), Screening Men age 35 years and older (20-35 at risk for CAD) Women age 45 years and older (20-45 at risk for CAD) One every 5 calendar year Colorectal Cancer, Screening 88141, 88142, 88143, 88147, 88148, 88150, 88152, 88153,88154, 88155, 88164, 88165, 88166, 88167, 88174, 88175, G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, 3000, P3001, or Q0091 with routine diagnosis gin combined with BRCA benefit above 87110, 87270, 87320, 87490, 87491, 87492, or 87810 with routine diagnosis or 87800, 86631 or 86632 with diagnosis codes V73.88 or V73.98 82465 or 83718 with routine diagnosis Age restriction set up at 20-99 years Same as COL rider Age restriction set up at 50-99 years Colonoscopy Once every 10 calendar years Ages 50-75 years Includes outpatient facility services, physician services, and anesthesia. Sigmoidoscopy Ages 50-75 years Once every 3 calendar years Barium Enema Part of standard COL Ages 50-75 years Once every 5 calendar years Hemocult Ages 50-75 years Colonoscopy G0121, G0105, 44388 44390, 44391-44394, 44397, 45355, 45378 45380, 45381 45387, 45391, or 45392 Anesthesia 00810,99143-99145,99148-99150 With routine diagnosis Sigmoidoscopy G0104 or 45330 with routine diagnosis Barium Enema G0106, G0120, G0122, or 74280 with routine diagnosis Hemocult G0107, G0328, G0394, 82270, 82272, or 82274 with routine diagnosis Anesthesia Prior to 07/01/11 00810, 99143-99145, 99148-99150 with routine diagnosis Effective 07/01/11 00810, 99143-99145, 99148-99150 covered when medical criteria is satisfied. (See Medical Policy # 470, Monitored Anesthesia Care) Age restriction set up at 50-99 years Age restriction set up at 50-99 years Age restriction set up at 50-99 years Revised 07/31/2012 LAM Page 2
Congenital Hypothyroidism, Screening Newborns - ages 2-4 days 84436, 84437, 84439, or 84443 with diagnosis V77.0 Dental Caries in Preschool Children, Prevention Included in preventive office visit Depression (Adults), Screening Ages 12 years and older 99401 with diagnosis V79.0 1/1/12 add G0444 6/30/12 cancel 99401 Developmental Screening 96110 with routine diagnosis Ages 9-30 months Four services during age range 1/1/12 add G0451 Developmental Surveillance for Children Included as part of an office visit Developmental/Behavioral Assessment Alcohol and Drug Ages 11-21 years One each calendar year Dyslipidemia Screening Ages 2-10 years: Once every 2 calendar years Ages 11-17 years: One each calendar year Ages 18 21 years: Once during age range Behavioral Counseling in Primary Care to Promote a Healthy Diet (Diet Counseling) Three hours each calendar year Ages 19 and older G0396, H0001, or 99408 with diagnosis V69.8 or V69.9 1/1/12 add G0442, G0443 6/30/12 cancel 99408 80061 with diagnosis V77.91 97802-97804, G0270 or G0271 with diagnosis V62.3, 249.00-250.93, 648.00-648.04, 401.0-414.07, 414.10-414.9, 425.0-425.9, 428.0-428.9, 429.1-429.3, 429.9, 278.00, 278.01, 649.10-649.14, V85.30-V85.39, V85.41- V85.45, 357.2, 362.0, or 366.41. 87590, 87591, 87850, 87800 or 87801 with diagnosis V74.5. Gonorrhea, Screening Female only Ages 11 and older Two per calendar year Gonorrhea, Prophylactic Medication, Newborn Hematocrit or Hemoglobin 85014 or 85018 with diagnosis V78.0 No code available - usually administered as an ancillary charge while inpatient at time of delivery Revised 07/31/2012 LAM Page 3
Ages 4 months-10 years, no more than 3 tests. Ages 11-21 years--one each calendar year Hepatitis B Virus Infection, Screening Females (pregnant) High Blood Pressure, Screening as needed. Ages 18 years and older HIV, Screening Ages 11 years and older No frequency *Beginning August 1, 2012 for females beginning at age 10. Human Papillomavirus (HPV) Part of Standard PMD Ages 30-99 years One every 3 calendar years Immunizations Pneumococcal Polysaccharide Vaccine 87340 and diagnosis V22.0-V23.9 Usually included as part of an office visit 86701, 87535, 87534, 87390, 86703, G0432, G0433, or G0435 with diagnosis V73.89. 1/1/12 add 87389 87620, 87621, or 87622 with routine diagnosis See Routine Immunizations Standard PMD Contracts on DORS Age change on Gardasil from 27 to 21 was effective on 10/25/11 Human Papilloma Virus (HPV) Vaccine- 90649 Gardasil Males Ages 9-21 years Inpatient Newborn Care Inpatient physician services only Newborns 99221-99223, 99231-99233, 99234-99236, 99238, 99239, 99460, 99462-99464, 99478-99480 with a routine diagnosis Iron Deficiency Anemia, Prevention Pharmacy Benefit Revised 07/31/2012 LAM Page 4
Iron Deficiency Anemia, Screening Females Lead Screening Ages 6 months 6 years 3 tests during age range Major Depressive Disorder in Children and Adolescents, Screening Ages 12-18 years Mammography and Digitization One baseline for females ages 35-39 years One annually for females age 40 and over Newborn Metabolic/Hemoglobin Screening Ages 0-2 months One test during age range Newborn Screening Panel Ages birth-31 days Obesity in Adults and Children Screening. Ages 6 years and older One per calendar year Oral Health Ages 6 months-6 years. 3 services during age range 85013, 85014, 85018, 85025, or 85027 with diagnosis V22.0-V23.9 83655 with diagnosis V82.5 99401 with diagnosis V79.0 1/1/12 add G0444 6/30/12 cancel 99401 G0202, G0204, G0236, 76085, 77051-77052, 77055, 77056, or 77057 with routine diagnosis S3620 with no specific diagnosis required 83788 with routine diagnosis V77.3 83498 or 83788 with routine diagnosis V77.99 83020 with routine diagnosis V78.3 82261 with routine diagnosis V77.99 83516 with routine diagnosis V77.6 82776 with routine diagnosis V77.4 86355 or 86359 with routine diagnosis V77.9 82760 with routine diagnosis V77.4 82759 with routine diagnosis V77.4 86359 with routine diagnosis V77.99 99401 with diagnosis V77.8 99420 with diagnosis V72.2 HCP did not list as covered we included in HCP so there would be no disruption of coverage Revised 07/31/2012 LAM Page 5
Osteoporosis in Postmenopausal Women, Screening 77080 with diagnosis V82.81 Age restriction set up at 0-99 years Effective 10/01/2010 01/31/2012 Ages 65 and older. 60 and older if at risk.. Once every 4 calendar years (prior to 2/1/12) Effective 02/01/2012 Ages 65 and older. 65 and younger if at risk. Once every 2 calendar years 77080 with diagnosis V13.51, V13.52, V15.51, V17.81, V45.77, V82.81, V87.45, 305.1, 714.0-714.9, 720.0, 250.01, 250.03, 250.11, 250.13, 250.21, 250.23, 250.31, 205.33, 250.41, 250.43, 250.51, 250.53, 250.61, 250.63, 250.71, 250.73, 250.81, 250.83, 250.91, 250.93, 756.51, 758.6, 242.00-242.91, 256.2, 256.31, 256.39, 253.4, 263.0,-263.9, V12.1, 579.0,-579.9, 571.0-571.9, 303.00-303.93 OR V11.3 The U.S. Preventive Services Task Force did not make a frequency recommendation. The frequency follows the recommendation made by the American College of Obstetrics and Gynecology. Phenylketonuria, Screening (PKU) 84030 with diagnosis V77.3 Ages 2-14 days Two tests during age range Prostate Specific Antigen (PSA) G0103 or 84153 with routine diagnosis Ages 40 years and over Annually Rh (D) Incompatibility, Screening 86901 with diagnosis V22.0-V23.9. Two per calendar year. Sexually Transmitted Infections, 99401-99404 with diagnosis V65.44, V65.45, or V69.2 Counseling 1/1/12 add G0445 Ages 11-99 years Three hours in a lifetime *Beginning August 1, 2012 for females, annually beginning at age 10. Sexually Transmitted Infections, 86631, 86632, 86701, 86703, 87081, 87110, Screening 87205, 87210, 87270, 87320, 87490, 87491, Ages 11-21 years 87590, 87591, 87800, 87810, or 87850 with No frequency diagnosis V74.5 Sickle Cell Disease, Screening 83020 or 83021 with diagnosis V78.2 Age 0-31 days No frequency Syphilis Infection, Screening 86592 or 86780 with diagnosis V74.5. HCP did not list as covered we included in HCP so there would be no disruption of coverage Revised 07/31/2012 LAM Page 6
No frequency Tobacco Use and Tobacco-Caused Disease, Counseling One of each CPT code each calendar year Ages 19-99 years Males and Females 99406 or 99407 with diagnosis 305.1, G0436, G0437 Females CPT codes 99406 or 99407 with ICD-9 code of 649.04. Type 2 Diabetes Mellitus in Adults, Screening Ages 19 years and older Once every 3 calendar years Tuberculin Test Ages 1 month - 2 years 6 tests during age range Visual Acuity Screening in Children Newborn age 10 limited to 8 tests in age range Ages 11-21 years limited to 4 tests during age range Prenatal Visits Prenatal conference with Pediatricians only Preventive History and Physical Examinations 9 visits the first 2 years of life Age 2 two per birth year Ages 3-6 - one each year ( based on birth year) Ages 7 and older one each calendar year Sensory Screening Hearing Ages 2 months - 10 years---no more than eight tests, Ages 11-21 years ----no more than two tests Screening Hearing Newborn Newborn 31 days One in a lifetime 82947 or 83036 with diagnosis V77.1 86580 with diagnosis V74.1 99173 or 99174 with diagnosis V72.0 CPT codes 99201-99203 or 99211-99213 and ICD-9 V65.11. 92551, 92552, 92567, 92586, 92587, or V5008 with diagnosis V20.2 or V72.19 1/1/12 add 92558 12/31/11 cancel 92587 92586 or 92587 with diagnosis V20.2, V20.31, V20.32, or V72.19 1/1/12 add 92558 12/31/11 cancel 92587 HCP indicates to cover an additional visit at age 30 months for well child Audiologists are not eligible providers Audiologists are not eligible providers Revised 07/31/2012 LAM Page 7
*Women s Preventive Screenings Effective August 1, 2012 Description Code Notes Well Woman Preventative beginning at age 10 99383-99387, G0438, or S0610, with diagnosis V70.0 or V72.31 limited to 1 visit each calendar year Preconception beginning at age 10 One visit per calendar year Prenatal Care beginning at age 10 99393-99397, G0439, S0612, or S0613 with diagnosis V70.0 or V72.31 limited to 2 visits each calendar year same procedure codes as above with diagnosis code V26.49 Code 59425 with diagnosis codes 640-649, 651-659.9, V22.0-V23.9 limited 2 visits per calendar year 59426 with diagnosis codes 640-649, 651-659.9, V22.0-V23.9 limited to one visit per calendar year Screening for Gestational Diabetes beginning at age 10 Limit two per calendar year HIV Counseling beginning at age 10 Annually 99201-99215 with diagnosis codes; 640-649, 651-659.9, V22.0-V23.9 limit 3 visits per calendar year 82947 or 83036 with ICD-9 diagnosis codes V22.0-V23.9 or 640.00-647.94,648.10-648.74,648.90-659.93or V91.00-V91.03, V91.09- V91.12 or V91.19-V91.22, V91.29, V91.90- V91.92, V91.99, 671.00, 671.03, 671.10, 671.13, 671.20, 671.23, 671.30, 671.33, 671.50, 671.53, 671.80, 671.83, 671.90, 671.93, 673.00, 673.03, 673.10, 673.13, 673.20, 673.23, 673.30, 673.33, 673.80, 673.83, 674.00, 674.03, 674.50, 674.53675.00, 675.03, 675.10, 675.13, 675.20, 675.23, 675.80, 675.83, 675.90, 675.93, 676.00, 676.03, 676.10, 676.13, 676.20, 676.23, 676.30, 676.33, 676.40, 676.43, 676.60, 676.63, 676.80, 676.83, 676.90, 676.93. 99401 or 99402 with diagnosis V65.44 Revised 07/31/2012 LAM Page 8
Contraceptive Methods and Counseling Counseling Female only beginning at age 10 Annually Sterilization Female only One procedure per lifetime Confirmatory Test Two in a lifetime 99401 or 99402 with diagnosis codes V25.01- V25.09, V25.40-V25.49, or V25.9 58565, 58600, 58605, 58611, 58615, 58670 58671, 00851, A4264 with diagnosis code V25.2 58565 has to have a confirmatory test 74740 and 58340 with diagnosis code V25.8 Note: injection code 96372 if Depo-Provera was given and the removal of contraceptive devices (11982,11976) were not added since we are unable to tie them back to matching procedure to provide accurate coverage) Medical Contraceptive Methods 11981, 11983, 57170, 58300, J1055, J1056, J7307, J7300, J7302, J7306, S4981, S4989, with diagnosis codes V25.02, V25.11, V25.13, V25.42, V25.43, V25.49, or V25.5 Pharmacy Contraceptive Methods Generic or Preferred Brand when generic is not available To be considered under the pharmacy plan when ordered by a physician and requires prescription to be filled for the coding Revised 07/31/2012 LAM Page 9
Breast Feeding Counseling and Support Three per year in conjunction with birth Supplies Pumps and Accessories Screening and Counseling for Interpersonal and Domestic Violence beginning at age 10 Annually 99401-99404 with modifier TH and diagnosis code V24.1 Pumps - E0602 or E0603 with type service H for rental Accessories - A4281, A4282, A4283, A4285, A4286 99401-99404 with diagnosis codes V61.11, V61.12, V61.21, V61.22, V62.83 The Patient Protection and Affordable Care Act (ACA) defines preventive care services as follows: Items or services recommended with an A or B rating by the U.S. Preventive Services Task Force. Immunization recommended by the Advisory Committee on Immunization Practices (ACIP) of the Center for Disease Control (CDC). (children, adolescent, and adult) Preventive care and screening for infants, children, and adolescents supported by the Health Resources and Services Administration (Bright Futures). Preventive care and screening for women supported by the Health Resources and Service Administration. (These guidelines have not been defined yet.) All providers (including those outside the state of Alabama) must use the codes provided in this document when filing claims for healthcare reform mandated preventive services for a Blue Cross and Blue Shield of Alabama member. If the preventive services section of a plan's benefit booklet refers to www.bcbsal.com/preventiveservices, the preventive services and immunizations in this document will be covered by the health plan. However, a group may decide to delay the effective date for coverage until the group's plan year for any new preventive services and immunizations recently added to this list. If a plan covers these services, please be aware that in some cases, routine preventive services and routine immunizations may be billed separately from an office or other facility visit. In that case, the applicable office visit or outpatient facility copayments described in the physician benefits and outpatient hospital benefits sections of the benefit booklet may apply. In any case, applicable office visit or facility copayments may still apply when the primary purpose for a visit is not routine preventive services and/or routine immunizations. If you have any questions about a plan s benefits, you may call our Customer Service Department at the number on the back of the ID card. Revised 07/31/2012 LAM Page 10