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 99201- 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 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) Updated on 12/19/2014 Preventive Health - Men - Coding Guidelines Page 1
Colorectal Cancer (con't) 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 V16.0 V18.51 V18.9 V76.41 V76.51 Z12.11 Z12.12 Z80.0 Z83.71 Z84.81 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 Type 2 Diabetes Mellitus High Blood Pressure 82947 Glucose; quantitative, blood (except reagent strip) Yes V77.1 Z13.1 83036 Hemoglobin; glycosylated (A1C) 99201- Yes V81.1 Z01.30 Z01.31 Z13.6 HIV 86689 Antibody; HTLV or HIV antibody, confirmatory test (eg, Western Blot) V73.89 Z11.4 Z20.6 86701 Antibody; HIV-1 86702 Antibody; HIV-2 86703 Antibody; HIV-1 and HIV-2, single result Updated on 12/19/2014 Preventive Health - Men - Coding Guidelines Page 2
HIV (con't) 87389 (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 Z20.6 87390 (eff 1/1/2013) Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; HIV-1 87391 (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 80061 Lipid panel V77.91 Z13.220 82465 Cholesterol, serum or whole blood, total 83718 Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) Syphilis 86592 Syphilis test, non-treponemal antibody; qualitative (e.g., VDRL, RPR, ART) 86780 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 Z20.828 Screening for hepatitis B virus (HBV) Aspirin for the prevention of Cardiovascular disease (CVD) 87340 Infectious agent antigen detection by enzyme immunoassay technique, V73.89 Z11.59 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) Covered through HMSA's Pharmacy Benefit Manager with prescription Updated on 12/19/2014 Preventive Health - Men - Coding Guidelines Page 3
Alcohol Misuse 99201- Yes 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 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. Depression 99201- Yes V79.0 Z13.89 96127 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 99201- Yes V15.82 305.1 Z71.6 Z87.891 F17.200 F17.201 F17.210 F17.211 F17.220 F17.221 F17.290 F17.291 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 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
Obesity 99201- Yes V70.1 V77.1 278.00 278.01 Z04.6 Z13.1 E66.01-E66.1 E66.8-E66.9 99411-99412 reduction intervention(s) provided to an individual or individuals in a group setting (separate procedure). Differences in codes are timebased. 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 Healthy Diet 99201- Sexually Transmitted Infections (STI) Nutritional counseling, dietitian visit 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 99201-99411- 99412 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: 250.00-250.93 401.0-401.9 272.0-272.9 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 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 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
Prevention of falls 99201- Yes V65.43 Z91.81 Vitamin D supplementation for the prevention of falls Covered through HMSA's Pharmacy Benefit Manager with prescription Skin cancer 99201- 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