PREVENTIVE SERVICES U.S. PREVENTIVE SERVICES TASK FORCE RECOMMENDATIONS

PREVENTIVE SERVICES U.S. PREVENTIVE SERVICES TASK FORCE RECOMMENDATIONS Policy Neighborhood Health Plan preventive care coverage complies with the Affordable Care Act (ACA). Services designated as preventive care include periodic well visits, routine immunizations and certain designated screenings. The U.S. Department of Health and Human Services also issued guidelines to ensure that all women have access to preventive health services necessary for women s health and well-being. These guidelines require health plans and health insurance issuers to cover the recommended women s preventive health services without charging a copayment, co-insurance, or deductible for in-network services. Preventive Care Services The ACA has designated specific resources that identify the preventive services required for coverage by the act. U.S. Preventive Services Task Force (USPSTF) A and B recommendations. Advisory Committee on Immunization Practices (ACIP) recommendations that have been adopted by the Director of the Centers for Disease Control. Recommendations of the ACIP appear in four immunization schedules. Comprehensive guidelines supported by the Health Resources and Services Administration (HRSA). - Guidelines for infants, children, and adolescents appear in two charts: the periodicity schedule of the Bright Futures Recommendations for Pediatric Preventive Health Care and the Uniform Panel of the Secretary s Advisory Committee on Heritable Disorders in Newborns and Children. - Guidelines specifically issued for women that became effective as applicable for health plans upon inception or renewal on or after August 1, 2012. Limitations All NHP in-network (contracted) providers must provide recommended services, as listed in this guideline, with no cost-sharing, including but not limited to any co-insurance, co-payments or deductibles. Preventive Services Page 1

Definitions Advisory Committee on Immunization Practices (ACIP): A committee of immunization experts selected by the Secretary of the U.S. Department of Health and Human Services to provide advice and guidance on the control of vaccine-preventable diseases. Benefit Period: If non-group coverage with NHP, benefit period resets on January 1 st. If enrolled through employer-sponsored group coverage with NHP, benefit period resets on employer s anniversary date. Bright Futures/American Academy of Pediatric Health Care: A national health promotion and disease prevention initiative that addresses children s health needs in the context of family and community. The recommendations for preventive pediatric health care guidelines represent a consensus by the American Academy of Pediatrics (AAP) and Bright Futures. Centers for Disease Control and Prevention (CDC): A major operating component of the U.S. Department of Health and Human Services whose mission is to create the expertise, information, and tools that people and communities need to protect their health. Heritable Disorders in Newborns and Children The Secretary s Advisory Committee (SACHDNC): This committee advises the most appropriate application of universal newborn screening tests, technologies, policies, guidelines and standards for effectively reducing morbidity and mortality in newborns and children having, or at risk for, heritable disorders. In-Network: Providers or health care facilities which are part of NHP s network of participating providers with which NHP has entered into an agreement/contract to provide covered services to NHP members. Office or other outpatient visit: An evaluation and management (E/M) service (sick visit) with history, examination, and medical decision making considered as the key components, provided in the physician s office or in an outpatient or other ambulatory facility. Patient Protection and Accountability Care Act (PPACA): A federal statute that was signed into law by the President of the United States of America on March 23, 2010. The legislation addresses several aspects of health care reform including but not limited to: health insurance coverage, payment for these new proposals, and the guidelines for preventive services. Preventive medicine visit: A comprehensive, preventive medical E/M service of an individual including an age appropriate history, exam, counseling, anticipatory guidance, risk factor reduction intervention(s), and the ordering of laboratory and/or diagnostic procedures. U.S. Preventive Services Task Force (USPSTF): An independent panel of non-federal experts in prevention and evidence-based medicine, composed of primary care providers (such as internists, pediatricians, family physicians, gynecologists/obstetricians, nurses, and health behavior specialists) who conduct scientific evidence reviews of a broad range of clinical health care services (such as Preventive Services Page 2

screening, counseling, and medications) and develop recommendations for primary care clinicians and health systems. These recommendations are published in the form of Recommendation Statements. Neighborhood Health Plan offers the following services with no member cost share when they are administrated by network doctors and hospitals: ICD-10 codes represent services that are not for treatment of illness or injury and should be submitted as the primary diagnosis for preventive service(s). Diagnoses and Procedure Codes Applicable To Guideline: USPSTF A and B Recommendations ICD-10 Diagnosis Codes (when required) G0389 Z13.89 99408 99409 Codes Topic Description Comment Abdominal aortic aneurysm screening: men Alcohol misuse counseling Aspirin to prevent CVD: women Aspirin to prevent CVD: men onetime screening for abdominal aortic aneurysm by ultrasonography in men aged 65 to 75 who have ever smoked. that clinicians screen adults age 18 years or older for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse. the use of aspirin for women age 55 to 79 years when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage. the use of aspirin for men ages 45 to 79 years when the potential benefit due to a reduction in myocardial infarctions outweighs the potential harm of an increase in gastrointestinal hemorrhage. Z13.6 Blood pressure screening screening for high blood pressure in adults aged 18 years and older. Not separately reimbursable Not separately reimbursable included in the well visit. Preventive Services Page 3

Falls prevention in older adults: exercise or physical therapy exercise or physical therapy to prevent falls in communitydwelling adults age 65 years and older who are at increased risk for falls. Not separately reimbursable included in the well visit. Z80.3 Z80.41 Z31.5 Z15.01 Z15.02 Z80.3 Z80.41 Z31.5 Z15.01 Z15.02 Z12.39 Z12.31 Z12.4 Z01.42 Falls prevention in older adults: vitamin D 96040 Genetic counseling for BRCA testing and BRCA lab screening 81211 81217 77052 77055 77056 77057 G0202 S9443 88141 88142 88143 88147 88148 88150 88152 88153 88154 Genetic testing of BRCA 1 and BRCA 2 for hereditary breast cancer and hereditary ovarian cancer syndrome. Breast cancer screening Breastfeeding counseling and class Cervical cancer screening vitamin D supplementation to prevent falls in community-dwelling adults age 65 years and older who are at increased risk for falls. The USPTF recommends that primary care providers screen women who have family members with breast, ovarian, tubal, or peritoneal cancer with one of several screening tools designed to identify a family history that may be associated with an increased risk for potentially harmful mutations in breast cancer susceptibility genes (BRCA 1 or BRCA 2). Women with positive screening results should receive genetic counseling and, if indicated after counseling, BRCA testing. BRCA 1 and/or BRCA 2 testing screening mammography for women, with or without clinical breast examination, every 1-2 years for women aged 40 and older. interventions during pregnancy and after birth to promote and support breastfeeding. The USPSTF strongly recommends screening for cervical cancer in women who have been sexually active and have a cervix. Prior authorization is required for BRCA genetic testing To report a pap smear, submit CPT codes, only. Preventive Services Page 4

Z13.220 Z13.6 88155 88164 88165 88166 88167 88174 88175 86631 86632 87270 87320 87491 80061 82465 83718 Chlamydial infection screening: women Cholesterol abnormalities screening: men 35 and older screening for Chlamydial infections for all sexually active women aged 24 and younger and for older non-pregnant women who are at increased risk. The USPSTF strongly recommends screening men aged 35 and older for lipid disorders. Cholesterol abnormalities screening: men younger than 35 screening men aged 20 to 35 for lipid disorders if they are at increased risk for coronary heart disease. Cholesterol abnormalities screening: women 45 and older The USPSTF strongly recommends screening women aged 45 and older for lipid disorders if they are at increased risk for coronary heart disease. Z85.038 Z85.048 Z80.0 Z83.71 Z83.79 Z12.10 Z12.11 Z12.12 45330 45331 45333 45338 45378 45380 45382 45384 45385 G0104 G0105 G0106 G0120 G0121 G0122 G0328 Cholesterol abnormalities screening: women younger than 35 Colorectal cancer screening Colorectal cancer screening G codes screening women aged 20 to 45 for lipid disorders if they are at increased risk for coronary heart disease. screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy, in adults, beginning at age 50 years and counting until age 75 years. The risks and benefits of these screening methods vary. screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy, in adults, beginning at age 50 years and counting until age 75 years. The risks and benefits of these screening methods vary. NHP covers members 20 years or older when medical necessity is present. Not payable, submit with valid CPT code. Preventive Services Page 5

Z41.8 99188 Dental caries prevention: infants and children up to age 5 years Z13.89 99201 99202 99211 99212 Depression screening: adolescents the application of fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption in primary care practices. The USPSTF recommends primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is fluoride deficient. screening of adolescents (12-18 years of age) for major depressive disorder when systems are in place to ensure accurate diagnosis, psychotherapy (cognitivebehavioral or interpersonal), and follow-up. Not separately reimbursable (included in the E/M visit) S3005 Depression screening: adults Depression screening: Postpartum screening adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and followup. Performance measurement, evaluation of patient selfassessment, depression Not separately reimbursable, reportable only code Z85.038 Z85.048 Z80.0 Z83.71 Z83.79 Z12.10 Z12.11 Z12.12 82270 82274 Fecal occult blood test Folic acid supplementation This test reports the presence (qualitative analysis) of blood in the stool. These codes are used to report the service when performed as colorectal neoplasm screening. all women planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid. O09.x Z11.3 Z33.1 Z34.x 87590 87591 87592 87850 Gonorrhea screening: women that clinicians screen all sexually active women, including those who are pregnant, for gonorrhea infection if they are at increased Preventive Services Page 6

risk for infection (that is, if they are young or have other individual or population risk factors). Z11.3 Z72.51 87590 87591 87592 87850 Z71.3 G0270 G0271 97802 97803 97804 99401 99402 Z00.110 Z00.111 Z00.129 92551 92552 92557 92587 Z13.0 83020 83021 85013 85014 85018 Gonorrhea screening: men Gonorrhea prophylactic medication: newborns Healthy diet counseling Hearing screening: newborns and children Hemoglobinopathies screening: newborns NHP recommends that clinicians screen all sexually men for gonorrhea infection if they are at increased risk for infection (that is, if they are young or have other individual or population risk factors). The USPSTF strongly recommends prophylactic ocular topical medication for all newborns against gonococcal opthalmia neonatorum. intensive behavioral dietary counseling for adult patients with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease. Intensive counseling can be delivered by primary care clinicians or by referral to other specialists, such as nutritionists or dietitians. screening for hearing loss in all newborn infants and children. screening for sickle cell disease in newborns. Reported with services included in: 99381 99391 Z01.84 86803 Hepatitis C screening screening for hepatitis C virus (HCV) in persons at high risk for infection. The USPSTF also recommends offering one-time screening for HCV infection to adults born between 1945 and 1965. O09.x Z33.1 Z34.x 87340 87341 Hepatitis B screening: pregnant women (HBsAg) The USPSTF strongly recommends screening for hepatitis B virus infection in pregnant women at their first prenatal visit. Preventive Services Page 7

O09.x Z11.59 Z33.1 Z34.1 Z00.00 Z01.411 Z01.419 Z11.51 Z12.4 Z13.29 84436 84437 84443 E66.9 E66.01 Z13.89 Z68.3x Z68.4x E66.9 E66.01 Z13.89 Z68.54 Z13.820 Z82.62 86701 HIV screening 86702 86703 86689 87390 87391 87534 87536 87537 87538 87539 86689 87623 Human Papillomavirus DNA testing 96150 96151 96152 96153 96150 96151 96152 96153 96154 76977 77078 77080 77081 Hypothyroidism screening: newborns Iron supplementation in children Obesity screening and counseling: adults Obesity screening and counseling: children Osteoporosis screening: women The USPSTF strongly recommends that clinicians screen for human immunodeficiency virus (HIV) all adolescents and adults at increased risk for HIV infections. screening for congenital hypothyroidism in newborns. routine iron supplementation for asymptomatic aged 6 to 12 months who are at increased risk for iron deficiency anemia. that clinicians screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained loss for obese patients. that clinicians screen children aged 6 years and older for obesity and offer them or refer them to comprehensive, intensive behavioral interventions to promote improvement in weight status. that women aged 65 and older be screened routinely for osteoporosis. The USPSTF recommends that routine screening begin at age 60 for women at increased risk for osteoporotic fractures. 84030 PKU screening: newborns screening for phenylketonuria (PKU) in newborns. To report screening, submit CPT codes, only. Women aged 30 or older Report only for patients less than 1 month old. Reported with services included in: 99381 99391 Preventive Services Page 8

O09.x Z33.1 Z34.x 86900 86901 Rh incompatibility screening: first pregnancy visit The USPSTF strongly recommends Rh (D) blood typing and antibody testing for all pregnant women during their first visit for pregnancy-related care. 86901 Z71.89 96150 96152 96153 99401 99402 99411 99412 Z11.3 86592 86593 Rh incompatibility screening: 24-28 weeks gestation STIs counseling Syphilis screening: nonpregnant persons repeated Rh (D) antibody testing for all unsensitized Rh (D) negative women at 24-28 weeks gestation, unless the biological father is known to be Rh (D) negative. highintensity behavioral counseling to prevent sexually transmitted infections (STIs) for all sexually active adolescents and for adults at increased risk for STIs. The USPSTF strongly recommends that clinicians screen persons at increased risk for syphilis infection. To report counseling, submit CPT codes, only. O09.x Z11.3 Z33.1 Z34.x F17.200 Z87.891 F17.200 O009.x O99.330 Z33.1 Z34.x Z87.891 86592 86593 99406 99407 G0436 99406 99407 G0436 Syphilis screening: pregnant women Tobacco use counseling: non pregnant adults Tobacco use counseling: pregnant women that clinicians screen all pregnant women for syphilis infection. that clinicians counsel all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products. that clinicians counsel all pregnant women about tobacco use and provide augmented, pregnancytailored counseling to those who smoke. The report counseling, submit CPT codes, only. Limited to 16 sessions per calendar year. The report counseling, submit CPT codes, only. Limited to 16 sessions per calendar year. O09.x Z11.3 Z33.1 Z34.x 82728 Anemia screening: pregnant women routine screening for iron deficiency anemia in asymptomatic pregnant women. Preventive Services Page 9

O09.x Z11.3 Z33.1 Z34.x Z00.129 99173 99174 Bacteriuria screening: pregnant women Visual acuity screening in children screening for asymptomatic bacteriuria with urine culture in pregnant women at 12 to 16 weeks' gestation or at the first prenatal visit, if later. screening to detect amblyopia, strabismus, and defects in visual acuity in children younger than 5 years of age. Modifiers Applicable to Guideline Modifier Descriptor Comments 33 Preventive service CPT modifier 33 is applicable to codes falling under recommendations by the PPACA of 2010 for the identification of preventive services without cost-sharing. If multiple preventive medicine services are provided on the same day then the modifier is appended to the codes for each preventive services rendered on that day. CPT codes not appended with modifier 33 will process under the member s medical or preventive benefits, based on the diagnosis and CPT codes submitted. U1 U2 Medicaid Level of Care: Completed behavioral health screening using a standardized behavioral health screening with no behavioral health need identified when administrated by a physician, independent nurse midwife or independent nurse practitioner. Medicaid Level of Care: Completed behavioral health screening using a standardized behavioral health and a behavioral health need was identified when administered by a physician, independent nurse midwife or independent nurse practitioner. For reimbursement of CPT 96110, append the appropriate U modifier to 96110. If a U modifier is not appended to 96110, the code will be reimbursed at $0.00. For reimbursement of CPT 96110, append the appropriate U modifier to 96110. If a U modifier is not appended to 96110, the code will be reimbursed at $0.00. U3 U4 U5 Medicaid Level of Care: Completed behavioral health screening using a standardized behavioral health screening with no behavioral health need identified when administered by a nurse midwife employed by a physician. Medicaid Level of Care: Completed behavioral health screening using a standardized behavioral health screening tool and a behavioral health need was identified when administered by a nurse midwife employed by a physician. Medicaid Level of Care: Completed behavioral health screening using a standardized behavioral health screening tool and a no behavioral health need identified when administered by a nurse For reimbursement of CPT 96110, append the appropriate U modifier to 96110. If a U modifier is not appended to 96110, the code will be reimbursed at $0.00. For reimbursement of CPT 96110, append the appropriate U modifier to 96110. If a U modifier is not appended to 96110, the code will be reimbursed at $0.00. For reimbursement of CPT 96110, append the appropriate U modifier to 96110. If a U modifier is not appended to 96110, the code will be reimbursed at $0.00. Preventive Services Page 10

U6 U7 U8 practitioner employed by a physician. Medicaid Level of Care: Completed behavioral health screening using a standardized behavioral health screening and a behavioral health need was identified when administered by a nurse practitioner employed by a physician. Medicaid Level of Care: Completed behavioral health screening using a standardized behavioral health screening tool with no behavioral health need identified when administered by a physician assistant employed by a physician. Medicaid Level of Care: Completed a behavioral health screening using a standardized behavioral health screening tool and a behavioral health need was identified when administered by a physician assistant employed by a physician. For reimbursement of CPT 96110, append the appropriate U modifier to 96110. If a U modifier is not appended to 96110, the code will be reimbursed at $0.00. For reimbursement of CPT 96110, append the appropriate U modifier to 96110. If a U modifier is not appended to 96110, the code will be reimbursed at $0.00. For reimbursement of CPT 96110, append the appropriate U modifier to 96110. If a U modifier is not appended to 96110, the code will be reimbursed at $0.00. Provider Payment Guidelines and Documentation: USPSTF A and B Recommendations Correctly coding preventive care services are keys to receiving accurate payment for those services. Preventive care services must be submitted with an ICD-10 code that represents health services encounters that are not for the treatment of illness or injury. The ICD-10 code must be placed in the first diagnosis position of the claim form (see the list of designated codes in the following table for each preventive service) If claims for preventive care services are submitted with diagnosis codes other than those noted on this PPG, such as a diagnosis codes that represent treatment of illness or injury, the service will not be identified as preventive care and claims will be paid using their normal medical benefits rather than preventive care coverage Services rated A or B by the US Preventive Services Task Force (USPSTF) Immunizations for routine use in children, adolescents, and adults as recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention Preventive care and screens for children as recommended by Bright Futures (American Academy of Pediatrics) and Newborn Testing (American College of Medical Genetics) Preventive care and screenings provided for women supported by the Health Resources and Services Administration. Women s Health and Well-Being: Women s Preventive Services: Service Diagnosis Procedure Preventive Contraceptive Methods and Counseling, and Patient Education Z30.0x Encounter for contraceptive management: general counseling and advice Z30.012 Encounter for prescription of 99401 Preventive medicine counseling; 99402 15-60 minutes (code is time 99403 dependent) 99404 Preventive Services Page 11

emergency contraception Z30.02 Counseling and instruction in natural family planning to avoid pregnancy 96150 Health and behavioral assessment 96151 96152 96153 Z30.09 Encounter for other general counseling and advice on contraception Z31.61 Procreative counseling and advice using natural family planning Preventive Sterilization Procedures Z30.2 Encounter for sterilization 58565 Hysteroscopy surgical; with the bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants 58600 Ligation of transection of fallopian tube(s) abdominal or vaginal approach, unilateral or bilateral 58605 Ligation or transection of fallopian tube(s), abdominal or vaginal approach, post-partum, unilateral or bilateral during same hospitalization 58611+ 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) 56815 Occlusion of fallopian tube(s) by device (i.e. band, clip, Falope ring) vaginal or suprapubic approach 58670 Laparoscopy, surgical; with occlusion of oviducts (w/wo transection) 58671 Laparoscopy, surgical; with occlusion of oviducts by device (i.e. band, clip, or Falope ring) 74740 Hysterosalpingography, radiological supervision & interpretation Preventive Post Sterilization A4264 Permanent implantable contraceptive intratubal occlusion device(s) and delivery system. Essure, Adiana Permanent Contraception Z98.51 Tubal ligation status 58340 Catherization and introduction of saline or contrast material for saline infusion Preventive Services Page 12

Procedures Preventive ORAL Hormonal Contraception Preventive Contraception Subdermal Implant Preventive Contraception, Barrier and Other Methods Preventive Contraceptive IUD Z30.011 Encounter for initial prescription of contraceptive pills Z30.49 Encounter for surveillance of other contraceptives Z97.5 Presence of (intrauterine) contraceptive device Z30.018 Encounter for initial prescription of other contraceptives Z30.9 Unspecified contraceptive management Z30.430 Encounter for insertion of intrauterine contraceptive device sonohysterography (SIS) or hysterosalpingography 74740 Hysterosalpingography, radiological supervision & interpretation 99201-99205 E/M Office Visit 99211-99215 11976 Removal, implantable contraceptive device 11981 Insertion, non-biodegradable drug delivery implant system (contraceptive capsules) 11982 Removal, non-biodegradable drug delivery implant 11983 Removal with reinsertion, nonbiodegradable drug delivery implant J7307 Etonogestrel (contraceptive) implant, including implant and supplies 57170 Diaphragm or cervical cap fitting with instructions 96372 Therapeutic injection 99201- E/M office visit 99205 99211-99215 A4261 Cervical caps A4266 Diaphragm for contraceptive use A4268 Female condom A4269 Contraceptive supply, spermicide (i.e. foam, gel), each J1050 Injection, medroxyprogesterone acetate, 1 mg J7303 Contraceptive supply, hormone containing vaginal ring, each J7304 Contraceptive supply, hormone containing patch, each 58300 Insertion of intrauterine device (IUD) Preventive Services Page 13

Procedures Preventive Contraception Surveillance Preventive Counseling for Interpersonal and Domestic Violence Anemia Screening: Pregnant Women Z30.431 Encounter for routine checking of intrauterine contraceptive device Z30.432 Encounter for removal of intrauterine contraceptive device Z30.433 Encounter for removal and reinsertion of intrauterine contraceptive device Z97.5 Presence of intrauterine contraceptive device Z30.431 Encounter for routine checking of intrauterine contraceptive device Z30.40 Encounter for surveillance of contraceptives, unspecified Z30.41 Encounter for surveillance of contraceptive pills Z30.49 Encounter for surveillance of other contraceptives Z69.11 Encounter for mental health services for victim of spousal or partner abuse Z69.12 Encounter for mental health services for perpetrator of spousal or partner abuse O09.x Supervision of pregnancy Z11.3 Encounter for screening for infections with a predominantly sexual mode of transmission Z33.1 Pregnant state, incidental Z34.x Encounter for supervision of pregnancy 58301 Removal of intrauterine device (IUD) 58562 Hysteroscopy surgical; with removal of foreign body J7300 Intrauterine copper contraceptive J7302 Levonorgestrel-releasing intrauterine contraceptive system 99201- E/M office visit 99205 99211- E/M office visit 99215 99401- Preventive medical counseling 99404 82728 Ferritin Bacteriuria Screening: Pregnant Women O09.x Supervision of pregnancy Z11.3 Encounter for screening for infections with a predominantly sexual mode of transmission Z33.1 Pregnant state, incidental 99201- E/M office visit 99205 99211- E/M office visit 99215 Preventive Services Page 14

Preventive Breast Feeding Counseling Preventive Breast Feeding Preventive Breast Feeding Support Breast Feeding Equipment and Supplies Z34.x Encounter for supervision of pregnancy Z39.1 Encounter for care and examination of lactating mother S9443 Breastfeeding counseling (Office setting) S9443-HQ Breastfeeding classes 99501 Home visit for postnatal assessment and follow up care Lactation Consultant Support up to 2 visits in the first year of life A4281 Tubing for breast pump, replacement A4282 Adapter for breast pump, replacement A4283 Cap for breast pump bottle, replacement A4284 Breast shield and splash protector for use with breast pump, replacement A4285 Polycarbonate bottle for use with breast pump, replacement A4286 Locking ring for breast pump, replacement E0602 Breast pump, manual, any type E0603 Breast pump electric, (AC or DC), any type (1 every 3 years) E0604 Breast pump, hospital grade, electric (AC or DC), any type (3 month rental) NOTE: Cost Sharing may not be applied to the above-listed preventive medicine visit codes when submitted for the applicable population, at the age appropriate intervals, and provided by an NHP contracted provider. Procedure Codes: ACIP Recommended Vaccine Code List Applicable to Guideline CPT Vaccine Descriptor Code 90620 Meningococcal recombinant protein and outer membrane vesicle vaccine, serogroup B (MenB), 2 dose schedule, for intramuscular use 90621 Meningococcal recombinant lipoprotein vaccine, serogroup B (MenB), 3 dose schedule, for intramuscular use 90630 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, for intradermal use 90632 Hepatitis A vaccine, adult dosage, for intramuscular use Preventive Services Page 15

90633 Hepatitis A vaccine, pediatric/adolescent dosage-2 dose schedule, intramuscular use 90634 Hepatitis A vaccine, pediatric/adolescent dosage-3 dose schedule, intramuscular use 90636 Hepatitis A and Hepatitis B vaccine (HepA-HepB) adult dosage, for intramuscular use 90644 Meningococcal conjugate vaccine, serogroups C & Y and Hemophilus influenza B vaccine (Hib-MenCY), 4 dose schedule, when administered to children 2-15 months of age, for intramuscular use 90645 Hemophilus influenza b vaccine (Hib), HbOC conjugate (4 dose schedule) intramuscular use 90646 Hemophilus influenza b vaccine (Hib), PRP-D conjugate, for booster use only, intramuscular use 90647 Hemophilus influenza b vaccine (Hib), PRP-OMP conjugate, (3 dose schedule) intramuscular use 90648 Hemophilus influenza b vaccine (Hib), PRP-T conjugate, (4 dose schedule) intramuscular use 90649 Human Papilloma virus (HPV) vaccine, types 6,11,16,18 (quadrivalent), 3 dose schedule, intramuscular use (i.e. Gardasil (Merck)) 90650 Human Papilloma virus (HPV) vaccine, types 16,18 (bivalent), 3 dose schedule, intramuscular use (i.e. Cervarix (GSK)) 90651 Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (HPV), 3 dose schedule, for intramuscular use 90654 Influenza virus vaccine, split virus, preservative-free, for intradermal use 90655 Influenza virus, split virus, preservative free, when administered to children 6-35 months of age for intramuscular use 90656 Influenza virus, split virus, preservative free, when administered to individuals 3 years or older, for intramuscular use 90657 Influenza virus, split virus, for children 6-35 months of age, intramuscular use 90658 Influenza virus, split virus, for individuals 3 years or older, intramuscular use 90660 Influenza virus vaccine, live, for intranasal use 90661 Influenza virus vaccine (cciiv3), derived from cell cultures, subunit, preservative and antibiotic free, for intramuscular use 90662 Influenza virus, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use 90664 Meningococcal conjugate vaccine, serogroups C & Y and Hemophilus influenza B vaccine (Hib-MenCY), 4 dose schedule, when administered to children 2-15 months of age, for intramuscular use 90669 Pneumococcal conjugate vaccine, 7 valent for intramuscular use 90670 Pneumococcal conjugate vaccine, 13 valent for intramuscular use (E.g. Prevnar 13) 90672 Influenza virus vaccine, quadrivalent, live, for intranasal use, 19 < 49; 90673 Influenza virus vaccine, trivalent, derived from recombinant DNA (RIV3), hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use 90680 Rotavirus vaccine, pentavalent, 3 dose schedule, live for oral use (E.g. RotaTeq) 90681 Rotavirus vaccine, human, attenuated, 2 dose schedule, live for oral use (E.g. Rotarix) 90685 Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use 90686 Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to individuals 3 years of age and older, for intramuscular use 90688 Influenza virus vaccine, quadrivalent, split virus, when administered to individuals 3 years of age and older, for intramuscular use 90690 Typhoid vaccine, live, oral 90691 Typhoid vaccine, Vi capsular polysaccharide (ViCPs), for intramuscular use 90696 Diphtheria, tetanus toxoids, acellular pertussis vaccine and poliovirus vaccine, inactivated (DTaP-IPV), when administered to children 4 through 6 years of age, for intramuscular use 90698 Diphtheria, tetanus toxoids, accellular pertussis vaccine, haemophilius influenza Type B and poliovirus vaccine, inactivated (Dtap-Hib-IPV) for intramuscular use (E.g. Pentacel) 90700 Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP) for individuals younger than 7 years, intramuscular use 90702 Diphtheria and tetanus toxoids (DT) adsorbed for individuals younger than 7 years, intramuscular use Preventive Services Page 16

90703 Tetanus toxoid adsorbed, for intramuscular use 90704 Mumps virus vaccine, live, for subcutaneous use 90705 Measles virus vaccine, live, for subcutaneous use 90706 Rubella virus vaccine, live, for subcutaneous use 90707 Measles, mumps and rubella vaccine (MMR), live, subcutaneous use 90708 Measles and rubella virus vaccine, live, for subcutaneous use 90710 Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use 90712 Poliovirus vaccine, (any type[s]) (OPV), live, for oral use 90713 Poliovirus vaccine, inactivated (IPV), subcutaneous or intramuscular use 90714 Tetanus and diphtheria toxoids (Td) adsorbed, preservative free, when administered to individuals 7 years or older, for intramuscular use 90715 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) for individuals 7 years or older, intramuscular 90716 Varicella virus vaccine, live, subcutaneous use 90717 Yellow fever vaccine, live, for subcutaneous use 90719 Diphtheria toxoid, for intramuscular use 90720 Diphtheria, tetanus toxoids, and whole cell pertussis vaccine and Hemophilus influenza B vaccine (DTP- Hib) for intramuscular use 90721 Diphtheria, tetanus toxoids and acellular pertussis vaccine and Hemophilus influenza B vaccine (Dtap- Hib) for intramuscular use 90723 Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitis B, and poliovirus vaccine, inactivated (DtaP-HepB-IPV) intramuscular use (E.g. Pediarix) 90725 Cholera vaccine for injectable use 90732 Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, 2 years or older, subcutaneous or intramuscular use 90733 Meningoccal polysaccharide vaccine (any group(s)), for subcutaneous use 90734 Meningococcal conjugate vaccine, (MCV4), serogroups A, C, Y and W-135 (tetravalent), intramuscular use 90736 Zoster (shingles) vaccine, live, for subcutaneous injection 90738 Japanese encephalitis virus vaccine, inactivated, for intramuscular use 90740 Hepatitis B vaccine, dialysis or immunocompromised patient dosage, (3 does schedule) for intramuscular use 90743 Hepatitis B vaccine, adolescent (2 dose schedule), intramuscular use 90744 Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), intramuscular use 90746 Hepatitis B vaccine, adult dosage, intramuscular use 90747 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), intramuscular use 90748 Hepatitis B and Hemophilus influenza b vaccine (HepB-Hib), for intramuscular use Immunization Administration for Vaccines/Toxoids Codes Applicable to Guideline Code Descriptor Comments 90460 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component For the first vaccine component reimbursed with a count of 1. 90461 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine/toxoid component (List separately in addition to code for primary procedure) For each additional component, in addition to CPT 90460, reimbursed with a count=>1 For billing tips, please refer to the Preventive Services Page 17

90471 Immunization administration, one vaccine (single or combination vaccine/toxoid) 90472 Immunization administration, one vaccine (single or combination vaccine/toxoid), each additional 90473 Immunization administration oral or intranasal; one vaccine 90474 Immunization administration oral or intranasal, each additional Vaccine and Immunization Provider Payment Guidelines Reimbursed with a count of 1 per day. Do not report with CPT 90473. Reimbursed with a count =>1, in addition to CPT 90471 or 90473 Reimbursed with a count of 1 per day. Do not report with CPT 90471. Reimbursed with a count =>1, in addition to CPT 90471 or 90473 G0008 Administration of influenza virus vaccine Reimbursed with a count of 1 per day G0009 Administration of pneumococcal vaccine Reimbursed with a count of 1 per day G0010 Administration of hepatitis B vaccine Reimbursed with a count of 1 per day NOTE: Cost Sharing may not be applied to the above-listed vaccines/toxoids and their administration when submitted for the applicable population in accordance with ACIP recommendations, and provided by an NHP provider. Vaccination Products Pending FDA Approval Code Descriptor Comments 90653 Influenza vaccine, inactivated (IIV), subunit, adjuvanted, for Non-reimbursable, pending FDA approval intramuscular use 90687 Influenza virus vaccine, quadrivalent (IIV4), split virus, when Non-reimbursable, pending FDA approval administered to children 6-35 months of age, for intramuscular use 90697 Diphtheria, tetanus toxoids, acellular pertussis vaccine, Non-reimbursable, pending FDA approval inactivated poliovirus vaccine, Haemophilus influenzae type b PRP-OMP conjugate vaccine, and hepatitis B vaccine (DTaP-IPV-Hib-HepB), for intramuscular use 90739 Hepatitis B vaccine (HepB), adult dosage, 2 dose schedule, for intramuscular use Non-reimbursable, pending FDA approval Related Policies NHP Coding NHP Colorectal Cancer Screening - Colonoscopy NHP Modifiers NHP Vaccine and Immunizations NHP Evaluation and Management (E/M) Services Preventive Services Page 18

References AMA CPT Assistant December 2010/Volume 20 Issue 12 ACIP vaccination recommendations: http://www.cdc.gov/vaccines/pubs/acip-list.htm ACIP Resolution No. 06/09-3: MMRV vaccine recommendations: http://www.cdc.gov/vaccines/programs/vfc/downloads/resolutions/0609mmrv-508.pdf ACIP Resolution No. 010/11-1: HPV vaccine recommendations: http://www.cdc.gov/vaccines/programs/vfc/downloads/resolutions/10-11-1-hpv.pdf Bright Futures Recommendations: http://brightfutures.aap.org/pdfs/aap%20bright%20futures%20periodicity%20sched%201011 07.pdf Additional Bright Futures information: http://www.brightfutures.org/ and/or http://www.pediatricsinpractice.org/index.asp?ck=pass The USPSTF A and B Recommendations: http://www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm The U S Preventive Services Task Force Recommendations, an A to Z Topic Guide: http://www.uspreventiveservicestaskforce.org/uspstopics.htm The Secretary's Advisory Committee on Heritable Disorders in Newborns and Children: http://www.hrsa.gov/heritabledisorderscommittee/ Implementation Center for the Recommended Preventive Services: http://www.healthcare.gov/center/regulations/prevention/recommendations.html The regulations issued by the U.S. Departments of Health and Human Services (HHS) (47 CFR Part 147), Labor (29 CFR Part 2590) and Treasury (26 CFR part 54) are recorded in the Federal Register/ Vol. 75, No. 137 / Monday, July 19, 2010, beginning on page 41726: http://edocket.access.gpo.gov/2010/pdf/2010-17565.pdf Clinical Preventive Services for Women, Closing the Gaps, July 19, 2011: Women s Preventive Services Recommended by IOM to be covered under Affordable Care Act: http://www.iom.edu/reports/2011/clinical-preventive-services-for-women-closing-the- Gaps.aspx Publication History Topic: Preventive Services: U.S. Preventive Services Task Force Recommendations Owner: Provider Network Management 2010/09/23 Original documentation 2011/05/06 Authorization grid and modifier grids updated, documentation guidelines, vaccine administration codes, references and disclaimer updated 2011/05/17 Modifiers U1-U8 updated Preventive Services Page 19

2011/08/08 Added chlamydial infection screening for all plan members, added limit to 16 sessions per calendar year for CPT 99406-9940, removed diagnosis requirement from CPT 96110. 2012/07/27 Annual review. Added Women s Health and Well-Being Codes. Updated diagnosis and procedure codes, vaccine code table; added NHP does not reimburse (effective 10/01/2012), under: Diagnoses and Procedure Codes Applicable to Guideline: USPSTF A and B Recommendations.Effective: August 1, 2012 2015/10/08 Updated procedure codes, expanded policy language, added ICD-10 codes, FDA pending table added This document is designed for informational purposes only. Claims payment is subject to member eligibility and benefits on the date of service, coordination of benefits, referral/authorization/notification and utilization management guidelines when applicable, adherence to plan policies and procedures, claims editing logic, and provider contractual agreement. In the event of a conflict between this payment guideline and the provider s agreement, the terms and conditions of the provider s agreement shall prevail. Neighborhood Health Plan utilizes McKesson s claims editing software, ClaimCheck, a clinically oriented, automated program that identifies the appropriate set of procedures eligible for provider reimbursement by analyzing the current and historical procedure codes billed on a single date of service and/or multiple dates of service, and also audits across dates of service to identify the unbundling of pre and post-operative care. Questions may be directed to Provider Network Management at prweb@nhp.org. Preventive Services Page 20