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, diagnosis and modifier code combinations that identify services covered under HMSA's Preventive Health Services policy. * For professional claims, the applicable ICD-9 or 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 33 when indicated. If modifier 33 is not appended, regular plan benefits will be applied. Preventive Service CPT or Bright Futures Recommendations Sensory Screening Vision 99173 Screening test of visual acuity, quantitative, bilateral Z00.121 Sensory Screening Hearing 92551 Screening test, pure tone, air only 92552 Pure tone audiometry (threshold); air only 92567 Tympanometry (impedance testing) 92558 Evoked otoacoustic emissions, screening (qualitative measurement of distortion product or transient evoked otoacoustic emissions), automated analysis Z00.121 Z38.00 Z38.01 Z38.1 Z38.2 Z38.30 Z38.31 Z38.4 Z38.5 Z38.61- Z38.66 Z38.68 Z38.69 Z38.7 Z38.8 Z01.10 Developmental Screening Autism Screening Alcohol and Drug Use Assessment 96110 Developmental screening (eg, developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument G0451 Development testing, with interpretation and report, per standardized instrument form 96110 Developmental screening (eg, developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument G0451 Development testing, with interpretation and report, per standardized instrument form 99408 Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes Z00.121 Z00.121 Z71.41 Z71.51 Updated on 08/21/2017 Preventive Health - Newborns and Children - Coding Guidelines Page 1
Alcohol and Drug Use Assessment (con't) 99409 Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; greater than 30 minutes 96160 Administration of patient; focused heath risk assessment instrument (eg, health hazard appraisal) with scoring and documentation, per standardized instrument Z71.41 Z71.51 Depression Screening 96110 Developmental screening (eg, developmental milestone survey, speech Z13.89 and language delay screen), with scoring and documentation, per standardized instrument 96160 Administration of patient; focused heath risk assessment instrument (eg, health hazard appraisal) with scoring and documentation, per standardized instrument 96127 Brief emotional/behavioral assessment (eg, depression inventory, attentiondeficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument Physical Examination 99460 Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant 99461 Initial care, per day, for evaluation and management of normal newborn infant seen in other than hospital or birthing center 99462 Subsequent hospital care, per day, for evaluation and management of normal newborn 99463 Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant admitted and discharged on the same date 99238 Hospital discharge day management; 30 minutes or less Z38.00 Z38.01 Z38.1 Z38.2 Z38.30 Z38.31 Z38.4 Z38.5 Z38.61- Z38.66 Z38.68 Z38.69 Z38.7 Z38.8 P00.3 P00.89 P00.9 99381-99385 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient (Differences in codes are age based) Z00.00 Z00.01 Z00.110 Z00.111 Z00.121 99391-99395 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient (Differences in codes are age based) Newborn Metabolic/ Hemoglobin Screening 36415 Collection of venous blood by venipuncture Yes S3620 Newborn metabolic screening panel, includes test kit, postage and the laboratory tests specified by the state for inclusion in this panel (e.g., galactose; hemoglobin, electrophoresis; hydroxyprogesterone, 17-d; phenylanine (PKU); and thyroxine, total) Z13.0 Z13.21 Z13.228 Z13.29 85018 Hemoglobin (Hgb) Updated on 08/21/2017 Preventive Health - Newborns and Children - Coding Guidelines Page 2
Hematocrit or Hemoglobin 36415 Collection of venous blood by venipuncture Yes Z13.0 85014 Hematocrit (Hct) 85018 Hemoglobin (Hgb) Lead Screening 36415 Collection of venous blood by venipuncture Yes Z13.88 83655 Lead Tuberculin Test 86580 Skin test; tuberculosis, intradermal Z11.1 Dyslipidemia Screening 36415 Collection of venous blood by venipuncture Yes Z13.220 80061 Lipid panel 82465 Cholesterol, serum or whole blood, total 83718 Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) 84478 Triglycerides STI Screening 36415 Collection of venous blood by venipuncture Yes 86631 Antibody; Chlamydia 86632 Antibody; Chlamydia, IgM 86701 Antibody; HIV-1 86703 Antibody; HIV-1 and HIV-2, single result 87081 Culture, presumptive, pathogenic organisms, screening only; 87110 Culture, chlamydia, any source 87210 Smear, primary source with interpretation; wet mount for infectious agents (eg, saline, India ink, KOH preps) 87270 Infectious agent antigen detection by immunofluorescent technique; Chlamydia trachomatis 87320 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; Chlamydia trachomatis Z01.812 Z01.84 Z01.89 Z11.3 Z11.8 Z11.9 87490 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, direct probe technique 87491 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique 87492 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, quantification 87590 Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, direct probe technique 87591 Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe technique 97592 Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, quantification 87800 Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s) technique 87801 Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified probe(s) technique Updated on 08/21/2017 Preventive Health - Newborns and Children - Coding Guidelines Page 3
STI Screening con't 87810 Infectious agent antigen detection by immunoassay with direct optical observation; Chlamydia trachomatis 87850 Infectious agent antigen detection by immunoassay with direct optical observation; Neisseria gonorrhoeae Z01.812 Z01.84 Z01.89 Z11.3 Z11.8 Z11.9 Cervical Dysplasia Screening 88141-88143 88147-88148 88150 88152-88155 88164-88167 88174-88175 Cytopathology, cervical or vaginal screening by various methods and to report physician interpretation services Z01.411 Z01.419 Z01.42 Z12.4 G0123-G0124 G0141 G0143-G0145 G0147-G0148 Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, screening by cytotechnologist under physician supervision P3000 P3001 Screening Papanicolaou smear, cervical or vaginal, up to 3 smears, reports by technician under physician supervision; or requiring interpretation by physician USPSTF A and B recommendations Congenital 36415 Collection of venous blood by venipuncture Yes Z13.29 84436 Thyroxine; total 84437 Thyroxine; requiring elution (eg, neonatal) 84439 Thyroxine; free 84443 Thyroid stimulating hormone (TSH) Phenylketonuria (PKU) 36415 Collection of venous blood by venipuncture Yes Z13.228 84030 Phenylalanine (PKU), blood Sickle cell anemia 36415 Collection of venous blood by venipuncture Yes Z13.0 Screening for hepatitis B virus (HBV) 83020 Hemoglobin fractionation and quantitation; electrophoresis (e.g., A2, S, C, and/or F) 83021 Hemoglobin fractionation and quantitation; chromatography (eg, A2, S, C, and/or F) 36415 Collection of venous blood by venipuncture Yes Z11.59 87340 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; hepatitis B surface antigen (HBsAg) 87341 Infectious 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) Updated on 08/21/2017 Preventive Health - Newborns and Children - Coding Guidelines Page 4
Prevention of dental caries Iron supplementation Covered through HMSA's Pharmacy Benefit Manager with prescription 99188 Application of topical fluoride varnish by a physician or other qualified various Covered through HMSA's Pharmacy Benefit Manager with prescription Obesity 99201-99205 99211-99215 Office or other outpatient visit for the evaluation and management of a new or established patient, which requires these 3 key components: A problem focused history; a problem focused examination; a straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Differences in codes are time-based. Yes Z04.6 Z13.1 E66.01-E66.1 E66.8-E66.9 99401-99404 99411-99412 Counseling. Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual or individuals in a group setting (separate procedure). Differences in codes are time-based. 97802 Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes 97803 Medical nutrition therapy; re-assessment and intervention, individual, faceto-face with the patient, each 15 minutes 97804 Medical nutrition therapy; group (2 or more individual(s)), each 30 minutes S9470 Skin cancer 99201-99205 99211-99215 Nutritional counseling, dietitian visit Office or other outpatient visit for the evaluation and management of a new or established patient, which requires these 3 key components: A problem focused history; a problem focused examination; a straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Differences in codes are time-based. Yes Z12.83 Z91.89 99401-99404 Counseling. Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure). Differences in codes are time-based. Tobacco Use and Tobacco Caused Disease 99201-99205 99211-99215 Office or other outpatient visit for the evaluation and management of a new or established patient, which requires these 3 key components: A problem focused history; a problem focused examination; a straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Differences in codes are time-based. Yes Z71.6 Z87.891 F17.200 F17.201 F17.210 F17.211 F17.220 F17.221 F17.290 F17.291 99401-99404 Counseling. Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure). Differences in codes are time-based. Updated on 08/21/2017 Preventive Health - Newborns and Children - Coding Guidelines Page 5
Tobacco Use and Tobacco Caused Disease (con't) 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 Syphilis 36415 Collection of venous blood by venipuncture Yes 86592 Syphilis test, non-treponemal antibody; qualitative (eg, VDRL, RPR, ART) 86780 Antibody; Treponema pallidum Z71.6 Z87.891 F17.200 F17.201 F17.210 F17.211 F17.220 F17.221 F17.290 F17.291 Z11.3 Z72.51 Z72.52 Z72.53 Updated on 08/21/2017 Preventive Health - Newborns and Children - Coding Guidelines Page 6