This document is obsolete.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 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 Well-Woman exam G0101 Cervical or vaginal cancer screening; pelvic and clinical breast examination V72.31 Z01.411 Z01.419 Breast Cancer 77057 Screening mammography, bilateral (2-view film study of each breast) V10.3 V16.3 77052 V76.11 Computer-aided detection (computer algorithm analysis of digital V76.12 image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; screening mammography (List separately in addition to code for primary procedure) G0202 Screening mammography, producing direct digital image, bilateral, all views Cervical Cancer 88141-88175 Cytopathology, cervical or vaginal screening by various methods and to report physician interpretation services G0141-G0148 Screening cytopathology smears, cervical or vaginal, performed by various methods and to report physician interpretation services Chlamydia 86631 Chlamydia V73.88 Z11.8 86632 Chlamydia, lgm V73.98 Colorectal Cancer 99201-99215 87110 Culture, chlamydia, any source 87270 Chlamydia trachomatis 87490 Chlamydia trachomatis, direct probe technique 87491 Chlamydia trachomatis, amplified probe technique Office or other outpatient visit for the evaluation and management of G0104 Colorectal cancer screening; flexible sigmoidoscopy G0105 Colorectal cancer screening; colonoscopy on individual at high risk V76.2 V72.31 V72.32 Yes V16.0 V18.51 V18.9 V76.41 V76.51 Z12.31 Z80.3 Z85.3 Z01.411 Z01.419 Z01.42 Z12.4 Z12.11 Z12.12 Z80.0 Z83.71 Z84.81 G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk Updated on 12/19/2014 Preventive Health - Women - Coding Guidelines 1
Colorectal Cancer (con't) 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 45340 with dilation by balloon, 1 or more strictures 45355 Colonoscopy, rigid or flexible, transabdominal via colotomy, single or multiple 45378 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) 45379 with removal of foreign body 45380 with biopsy, single or multiple 45381 with directed submucosal injection(s), any substance 45382 with control of bleeding (e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) 45383 with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique 45384 with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery 45385 with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 45386 with dilation by balloon, 1 or more strictures 45387 with transendoscopic stent placement (includes predilation) 45391 with endoscopic ultrasound examination 45392 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 82270 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) 82274 Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations V16.0 V18.51 V18.9 V76.41 V76.51 Z12.11 Z12.12 Z80.0 Z83.71 Z84.81 Updated on 12/19/2014 Preventive Health - Women - Coding Guidelines 2
Gonorrhea 87081 Culture, presumptive, pathogenic organisms, screening only V74.5 Z11.3 High Blood Pressure 87205 Smear, primary source with interpretation; Gram or Giemsa stain for bacteria, fungi, or cell types 87590 Neisseria gonorrhoeae, direct probe technique 87591 Neisseria gonorrhoeae, amplified probe technique 87492 Chlamydia trachomatis, quantification 87800 Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s) technique 87801 amplified probe(s) technique Yes V81.1 Z01.30 Z01.31 Z13.6 HIV 86689 HTLV or HIV antibody, confirmatory test (e.g., Western Blot) V73.89 86701 HIV-1 86702 HIV-2 86703 HIV-1 and HIV-2, single assay 87389 (eff 1/1/2013) 87390 (eff 1/1/2013) 87391 (eff 1/1/2013) G0432 G04 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 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; HIV-1 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; HIV-2 Infectious agent antigen detection by enzyme immunoassay (EIA) technique, qualitative or semi-quantitative, multiple-step method, HIV- 1 or HIV-2, screening Infectious agent antigen detection by enzyme-linked immunosorbent assay (ELISA) technique, antibody, HIV-1 or HIV-2, screening G0435 Infectious agent antigen detection by rapid antibody test of oral mucosa transudate, HIV-1 or HIV-2, screening Z11.4 Z20.6 Updated on 12/19/2014 Preventive Health - Women - Coding Guidelines 3
HIV con't Human papillomavirus testing Screening for hepatitis C virus (HCV) Screening for hepatitis B virus (HBV) 99401-99404 99411-99412 Counseling. Preventive medicine counseling and/or risk factor 87624 Infectious agent detection by nucleic acid (DNA or RNA); human papillomavirus (HPV), high-risk types (eg, 16, 18, 31,, 35, 39, 45, 51, 52, 56, 58, 59, 68) 87625 Infectious agent detection by nucleic acid (DNA or RNA); human papillomavirus (HPV), types 16 and 18 only, includes type 45, if performed G0472 Hepatitis C antibody screening for individual at high risk and other covered indication(s) 87340 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; hepatitis B surface antigen (HBsAg) 87341 Infectiour agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; hepatitis B surface antigen (HBsAg) 86704 Hepatitis B core antibody (HBcAb); total 86705 Hepatitis B core antibody (HBcAb); IgM antibody 86706 Hepatitis B surface antibody (HBsAb) Yes V73.89 Z11.4 Z20.6 V73.89 Z11.59 Lipid Disorders 80061 Lipid panel V77.91 Z13.220 82465 Cholesterol, serum or whole blood, total 83718 Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) Syphilis 80055 Obstetric panel Type 2 Diabetes Mellitus 86592 Syphilis test, non-treponemal antibody; qualitative (e.g., VDRL, RPR, ART) 86780 Antibody; influenza virus. Treponema pallidum. 82947 Glucose; quantitative, blood (except reagent strip) Yes V77.1 Z13.1 83036 Hemoglobin; by copper sulfate method, non-automated. Glycosylated (A1C). Osteoporosis 76977 Ultrasound bone density measurement and interpretation, peripheral site(s), any method 77078 Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine) 77080 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine) 77081 appendicular skeleton (peripheral) (e.g., radius, wrist, heel) V73.81 V76.2 V76.47 V73.89 V01.79 V69.2 V74.5 V82.81 V49.81 Z11.51 Z12.4 Z12.72 Z11.59 Z20.5 Z20.828 Z11.3 Z72.51-Z72.53 Z13.820 Z78.0 Updated on 12/19/2014 Preventive Health - Women - Coding Guidelines 4
Depression 96127 Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale, with scoring and documentation, per standardized instrument Alcohol Misuse Aspirin for the prevention of Cardiovascular disease (CVD) Folic acid to prevent neural tube defects Tobacco Use and Tobacco Caused Disease 99408-99409 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. Covered through HMSA's Pharmacy Benefit Manager with prescription Covered through HMSA's Pharmacy Benefit Manager with prescription Yes V79.0 Z13.89 99406 Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes 99407 Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes Yes Yes V15.82 305.1 V65.42 V79.1 291.0-291.5 303.00-303.93 305.00-305.03 Z71.41 F10.10-F10.151 F10.20-F10.229 F10.231 F10.250- F10.251 F10.26-F10.27 F10.920-F10.97 Z71.6 Z87.891 F17.200 F17.201 F17.210 F17.211 F17.220 F17.221 F17.290 F17.291 Updated on 12/19/2014 Preventive Health - Women - Coding Guidelines 5
Tobacco Use and Tobacco Caused Disease con't 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 Obesity 99401-99404 99411-99412 Counseling. Preventive medicine counseling and/or risk factor 97802 Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes 97803 re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes 97804 group (2 or more individual(s)) each 30 minutes S9470 Nutritional counseling, dietitian visit Healthy Diet V15.82 305.1 Yes V70.1 V77.1 278.00 278.01 97802 Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes 97803 re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes 97804 group (2 or more individual(s)) each 30 minutes S9452 S9470 Nutrition classes, nonphysician provider, per session Nutritional counseling, dietitian visit Yes V65.3 with one of the following additional diagnoses: 250.00-250.93 401.0-401.9 272.0-272.9 Z71.6 Z87.891 F17.200 F17.201 F17.210 F17.211 F17.220 F17.221 F17.290 F17.291 Z04.6 Z13.1 E66.01-E66.1 E66.8-E66.9 Z71.3 with one of the following aditional diagnoses: E10.10-E10.9 E11.00-E11.9 E13.00-E13.9 I10 E71.30 E75.21-E75.22 E75.240-E75.3 E75.5-E75.6 E77.0-E77.9 E78.0-E78.70 E78.79-E78.9 E88.1-E88.2 E88.89 Updated on 12/19/2014 Preventive Health - Women - Coding Guidelines 6
Counseling for Sexually Transmitted Infections (STI) Contraceptive methods and counseling 99401-99404 99411-99412 Counseling. Preventive medicine counseling and/or risk factor 11976 Removal, implantable contraceptive capsules 11981 Insertion, non-biodegradable drug delivery implant 11982 Removal, non-biodegradable drug delivery implant 11983 Removal with reinsertion, non-biodegradable drug delivery implant 57170 Diaphragm or cervical cap fitting with instructions 58300 Insertion of intrauterine device (IUD) 58301 Removal of intrauterine device (IUD) 58565 Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants 58600 Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral 58605 Ligation or transection of fallopian tube(s), abdominal or vaginal approach, postpartum, unilateral or bilateral, during same hospitalization (separate procedure) 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) 58615 Occlusion of fallopian tube(s) by device (eg, band, clip, Falope ring) vaginal or suprapubic approach 58670 Laparoscopy, surgical; with fulguration of oviducts (with or without transection) 58671 Laparoscopy, surgical; with occlusion of oviducts by device (eg, band, clip, or Falope ring) J1055 Injection, medroxyprogesterone acetate for contraceptive use, 150 mg J1056 Injection, medroxyprogesterone acetate / estradiol cypionate, 5mg / 25mg Yes V15.89 V65.44 V65.45 V69.2 J7300 J7302 J7306 J7307 Intrauterine copper contraceptive Levonorgestrel-releasing intrauterine contraceptive system, 52 mg Levonorgestrel (contraceptive) implant system, including implants and supplies Etonogestrel (contraceptive) implant system, including implant and supplies V25.01 V25.02 V25.03 V25.04 V25.09 V25.11 V25.12 V25.13 V25.2 V25.40 V25.41 V25.42 V25.43 V25.49 V25.5 V25.8 V25.9 Z70.0-Z70.1 Z71.7 Z71.89 Z72.51-Z72.53 Z77.21 Z77.9 Z91.89 Z30.011 Z30.012 Z30.013 Z30.014 Z30.018 Z30.019 Z30.02 Z30.09 Z30.2 Z30.40 Z30.41 Z30.42 Z30.430 Z30.431 Z30.432 Z30.4 Z30.49 Z30.8 Z30.9 Updated on 12/19/2014 Preventive Health - Women - Coding Guidelines 7
Contraceptive methods and counseling con't J3490 (Billed with NDC 50419-0422-01) Q0090 (eff 7/1/2013) S4981 S4989 Screening and 99401-99404 counseling for 99411-99412 interpersonal and domestic violence Skyla (Levonorgestrel-releasing intrauterine system) Insertion of levonorgestrel-releasing intrauterine system Contraceptive intrauterine device (e.g., Progestacert IUD), including implants and supplies Additional contraceptives covered under HMSA s drug riders are processed through CVS Caremark: Contraceptive Diaphragms/Cervical Caps, Generic Oral Contraceptives, and Contraceptive Other Methods (e.g. ring and patch) including all FDA approved OTC female contraceptives Counseling. Preventive medicine counseling and/or risk factor Chemoprevention of breast cancer Yes V25.01 V25.02 V25.03 V25.04 V25.09 V25.11 V25.12 V25.13 V25.2 V25.40 V25.41 V25.42 V25.43 V25.49 V25.5 V25.8 V25.9 Z30.011 Z30.012 Z30.013 Z30.014 Z30.018 Z30.019 Z30.02 Z30.09 Z30.2 Z30.40 Z30.41 Z30.42 Z30.430 Z30.431 Z30.432 Z30.4 Z30.49 Z30.8 Z30.9 Yes various various Yes V16.3 Z80.3 Updated on 12/19/2014 Preventive Health - Women - Coding Guidelines 8
Risk reduction of primary breast cancer Prevention of falls 99201-99205 99211-99215 Vitamin D supplementation for the prevention of falls Skin cancer 99201-99205 99211-99215 Covered through HMSA's Pharmacy Benefit Manager with prescription Office or other outpatient visit for the evaluation and management of Covered through HMSA's Pharmacy Benefit Manager with prescription Office or other outpatient visit for the evaluation and management of Yes V65.40 Z71.9 Yes V65.43 Z91.81 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 - Women - Coding Guidelines 9