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 Z01.411 Z01.419 Breast Cancer 77067 Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed G0202 Cervical Cancer 88141-88143 88147-88148 88150 88152-88155 88164-88167 88174-88175 Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed Cytopathology, cervical or vaginal screening by various methods and to report physician interpretation services Z12.31 Z80.3 Z85.3 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, by technician under physician supervision Screening Papanicolaou smear, cervical or vaginal, up to 3 smears, requiring interpretation by physician Chlamydia 86631 Chlamydia Z11.8 Colorectal Cancer 86632 Chlamydia, lgm 87110 Culture, chlamydia, any source 87270 Chlamydia trachomatis 87490 Chlamydia trachomatis, direct probe technique 87491 Chlamydia trachomatis, amplified probe technique Yes Z12.11 Z12.12 Z80.0 Z83.71 Z84.81 Updated on 3/21/2017 Preventive Health - Women - Coding Guidelines 1
Colorectal Cancer (con't) S0285 G0104 G0105 G0121 Colonoscopy consultation performed prior to a screening colonoscopy procedure Colorectal cancer screening; flexible sigmoidoscopy Colorectal cancer screening; colonoscopy on individual at high risk Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk Z12.11 Z12.12 Z80.0 Z83.71 Z84.81 450 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 45340 with dilation by balloon, 1 or more strictures 45346 with ablation of tumor(s), polyp(s), or other lesion(s) (includes preand post-dilation and guide wire passage, when performed) 45349 with endoscopic mucosal resection 45350 with band ligation(s) (eg, hemorrhoids) 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) 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 45388 with ablation of tumor(s), polyp(s), or other lesion(s) (includes preand post-dilation and guide wire passage, when performed) 45390 with endoscopic stent placement (includes pre- and post-dilation and guide wire passage, when performed) 45391 with endoscopic ultrasound examination 45392 with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s) 45393 with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube, when performed 45398 with band ligation(s) (eg, hemorrhoids) G0328 Colorectal cancer screening; fecal occult blood test, immunoassay, 1-3 simultaneous determinations Updated on 3/21/2017 Preventive Health - Women - Coding Guidelines 2
Colorectal Cancer (con't) 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 00810 Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum 88304 Level III - Surgical pathology, gross and microscopic examination 88305 Level IV - Surgical pathology, gross and microscopic examination 88312 Special stain including interpretation and report; Group I for microorganisms (eg, acid fast, methenamine silver) 88313 Special stain including interpretation and report; Group II, all other (eg, iron, trichrome), except stain for microorganisms, stains for enzyme constituents, or immunocytochemistry and immunohistochemistry Z12.11 Z12.12 Z80.0 Z83.71 Z84.81 88341 Immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in addition to code for primary procedure) 88342 Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure Gonorrhea 87081 Culture, presumptive, pathogenic organisms, screening only Z11.3 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 87592 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 amplified probe(s) technique High Blood Pressure Yes Z01.30 Z01.31 Z13.6 HIV 86689 HTLV or HIV antibody, confirmatory test (e.g., Western Blot) 86701 HIV-1 86702 HIV-2 86703 HIV-1 and HIV-2, single assay 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 Z11.4 Z20.6 Updated on 3/21/2017 Preventive Health - Women - Coding Guidelines 3
HIV con't 87390 (eff 1/1/2013) Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; HIV-1 Z11.4 Z20.6 87391 (eff 1/1/2013) Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; HIV-2 G0432 Infectious agent antigen detection by enzyme immunoassay (EIA) technique, G04 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 G0475 HIV antigen/antibody, combination assay, screening Yes 99401-99404 99411-99412 Counseling. Preventive medicine counseling and/or risk factor reduction Human papillomavirus testing 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 Z11.51 Z12.4 Z12.72 G0476 Infectious agent detection by nucleic acid (DNA or RNA); human papillomavirus HPV), high-risk types (e.g., 16, 18, 31,, 35, 39, 45, 51, 52, 56, 58, 59, 68) for cervical cancer screening, must be performed in addition to pap test Screening for hepatitis C virus (HCV) G0472 Hepatitis C antibody screening for individual at high risk and other covered indication(s) Z11.59 Z20.5 Z20.828 Screening for hepatitis B virus (HBV) 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) Z11.59 86704 Hepatitis B core antibody (HBcAb); total 86705 Hepatitis B core antibody (HBcAb); IgM antibody 86706 Hepatitis B surface antibody (HBsAb) Lipid Disorders 80061 Lipid panel Z13.220 82465 Cholesterol, serum or whole blood, total 83718 Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) Updated on 3/21/2017 Preventive Health - Women - Coding Guidelines 4
Syphilis 86592 Syphilis test, non-treponemal antibody; qualitative (e.g., VDRL, RPR, ART) 86780 Antibody; Treponema pallidum. Z11.3 Z72.51 Z72.52 Z72.53 Type 2 Diabetes Mellitus 82947 Glucose; quantitative, blood (except reagent strip) Yes 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 Z13.820 Z78.0 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) Depression Yes Z13.89 96127 Brief emotional/behavioral assessment (eg, depression inventory, attentiondeficit/hyperactivity disorder [ADHD] scale, with scoring and documentation, per standardized instrument Alcohol Misuse Yes 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. Aspirin for the prevention of Cardiovascular disease (CVD) Folic acid to prevent neural tube defects Covered through HMSA's Pharmacy Benefit Manager with prescription Covered through HMSA's Pharmacy Benefit Manager with prescription Updated on 3/21/2017 Preventive Health - Women - Coding Guidelines 5
Tobacco Use and Tobacco Caused Disease Yes 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 Obesity 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 97802 Medical nutrition therapy; initial assessment and intervention, individual, faceto-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 Nutritional counseling, dietitian visit Yes 97802 Medical nutrition therapy; initial assessment and intervention, individual, faceto-face with the patient, each 15 minutes 97803 re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes Z71.3 with one of these 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 E78.00-E78.70 E78.79-E78.9 E88.1-E88.2 E88.89 97804 group (2 or more individual(s)) each 30 minutes S9452 Nutrition classes, nonphysician provider, per session S9470 Nutritional counseling, dietitian visit Updated on 3/21/2017 Preventive Health - Women - Coding Guidelines 6
Counseling for Sexually Transmitted Infections (STI) Yes Z70.0-Z70.1 Z71.7 Z71.89 Z72.51-Z72.53 Z77.21 Z77.9 Z91.89 99401-99404 99411-99412 Counseling. Preventive medicine counseling and/or risk factor reduction Contraceptive methods and counseling 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 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) Z30.011-Z30.019 Z30.02 Z30.09 Z30.2 Z30.40-Z30.42 Z30.430-Z30.4 Z30.44-Z30.46 Z30.49 Z30.8 Z30.9 J1050 J7297 J7298 Injection, medroxyprogesterone acetate, 1 mg Levonorgestrel-releasing intrauterine contraceptive system (Liletta), 52 mg Levonorgestrel-releasing intrauterine contraceptive system (Mirena), 52 mg J7300 J7301 Intrauterine copper contraceptive Levonorgestrel-releasing intrauterine contraceptive system (Skyla), 13.5 mg J7306 J7307 Levonorgestrel (contraceptive) implant system, including implants and supplies Etonogestrel (contraceptive) implant system, including implant and supplies S4981 S4989 Insertion of levonorgestrel-releasing intrauterine system Contraceptive intrauterine device (e.g., Progestacert IUD), including implants and supplies Updated on 3/21/2017 Preventive Health - Women - Coding Guidelines 7
Contraceptive methods and counseling con't Yes Z30.011-Z30.019 Z30.02 Z30.09 Z30.2 Z30.40-Z30.42 Z30.430-Z30.4 Z30.44-Z30.46 Z30.49 Z30.8 Z30.9 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 Screening and counseling for interpersonal and domestic violence 99401-99404 99411-99412 Counseling. Preventive medicine counseling and/or risk factor reduction Yes various Chemoprevention of breast cancer Yes Z80.3 Risk reduction of primary breast cancer Yes Z71.9 Covered through HMSA's Pharmacy Benefit Manager with prescription Updated on 3/21/2017 Preventive Health - Women - Coding Guidelines 8
Prevention of falls Yes Z91.81 Vitamin D supplementation for the prevention of falls Skin cancer Covered through HMSA's Pharmacy Benefit Manager with prescription Yes Z12.83 Z91.89 Lung Cancer G0297 Low dose CT scan (LDCT) for lung cancer screening Z12.2 Updated on 3/21/2017 Preventive Health - Women - Coding Guidelines 9