1 2 3 4 5 Recommendation Adult Aortic Aneurysm Screening (one time age 65-75 if ever smoked) Alcohol & Drug Misuse Screening and Behavioral Counseling Intervention Aspirin for the Prevention of Cardiovascular Disease Men 45-79 Aspirin for the Prevention of Cardiovascular Disease Women 55-79 Asymptomatic Bacteriuria in Adults, Screening covered in full for adults >50 covered in full when provided by PCP or OB/GYN covered in full for men 45-79 covered In full for women 55-79 covered in full for pregnant women covered in full for Men only, age 65-75 covered in full when provided by PCP or OB/GYN covered in full for men 45-79 covered In full for women 55-79 covered in full for pregnant women ASO. Based on the G0389 99408, 99409, G0396, G0397. G0442, G0443 for 2012 Will be billed with NDC to pharmacy (script required) but paid as medical benefit Will be billed with NDC to pharmacy (script required) but paid as medical benefit 87081and 87084 87086 and 87088 with diagnosis 4158F, 4320F, 3016F 4011F, G8598, G8599 4011F, G8598, G8599 V81.5, V22.xx, V23.xx, V28.9x, 651.XX, 646.5 6 Breast Cancer Screening (Biennial 50-74) covered in full for women > 35 unless med nec: 1 baseline age 35-39; annual age 40+; additionally: 1 mammogram per year for individual, any age, having a prior history of breast cancer or a 1st degree relative with prior history of breast cancer covered in full for women > 40 for ASO; covered in full for women > 35 for DP/HNY 77051, 77055, 70556, G0204, G0206 with dx edits, 77052, 77057, G0202 no dx needed 3014F V76.11, V76.12 Page 1 of 19
7 8 8w Recommendation Breast and Ovarian Cancer Susceptibility, Genetic Risk Assessment and BRCA Mutation Testing Based on Family Risk Factors Breastfeeding, Primary Care Interventions to Promote Breastfeeding support, supplies and counseling ASO. Based on the 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255, 96040, S0265 with dx edits S9443 (code for classes) E0603 purchase or rental, E0604 RR for pump rental., A4281, A4282, A4283, A4284, A4285, A4286 for supplies. V26.33, V84.01, V84.02, V16.3, V16.41 9 Cervical Cancer Screening if Sexually Active 1 per year covered in full 1 per year covered in full 88141, 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88154,88155, 88164, 88165, 88166, 88167, 88174, 88175 with dx edits, G0101, G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001 no dx edits needed V76.2, V72.3x, V76.2, V72.31, 9w Human papillomavirus testing >29 every 3 years covered in full >29 every 3 years covered in full 87620, 87621, 87622 with Dx edits V73.81, V76.2, V72.31, V76.47 Page 2 of 19
10 11 Recommendation Chlamydial Infection, Screening; non pregnant women and pregnant women Colorectal Cancer Screening (Beginning at 50 and continuing to 75) Fecal occult blood testing: annual Sigmoidoscopy: every 5 years Colonoscopy: every 10 years ASO. Based on the covered in full for women covered in full for women covered in full for adults >50 covered in full for adults age 50-75 87270, 87320, 87800, 87801, 87810 with dx edits, 87490, 87491, 87492 no dx needed 82270, 82274, 88305, G0328, S0601, 45330, 45331, 45332, 45333, 45334, 45335, 45337, 45338, 45339, 45340, 45341, 45342, 45345, 44388, 44389, 44390, 44391, 44392, 44393, 44394, 44397, 45355, 45378, 45379, 45380, 45381, 45382, 45383, 45384, 45385, 45386, 45387, 45391, 45392, 74263 with dx edits; 00810 4293F 651.xx, V01.6, V15.85, V22.xx, V23.xx, V28.8, V28.9, V69.2, V72.3, V76.2, V73.88, V73.98, V74.5 V76.41, V76.50, V76.51, V76.52 G0104, G0105, G0121 is always screening by definition. No dx needed. 12 Congenital Hypothyroidism Screening (Newborns) covered in full for children less than one year of age covered in full for children less than one year of age 84436, 84437,84439, 84443, 84479, S3620 with dx edits V77.0 Page 3 of 19
13 14 15 Recommendation Dental Caries in Preschool Children, Prevention (prescribe oral fluoride if deficient in water) Depression (Adults) Screening (When staff-assisted depression care supports are in place) Major Depressive Disorders in Adolescents, Screening Diet, Behavioral Counseling in Primary Care for Adults with Hyperlipidemia and Other Risk Factors covered in full for children 6 mo-5 yrs covered in full for children 6 mo-5 yrs ASO. Based on the covered in full for all adults covered in full for adults > 19 16 Gonorrhea Screening covered in full for women covered in full for women 17 Gonorrhea, Prophylactic Eye Medication, (Newborns) 18 Hearing Loss in Newborns, Screening covered in full for children < 1 covered in full for children < 1 Will be billed with NDC to pharmacy (script required) but paid as medical benefit Generally part of visit and not coded separately. G0444 eff 2012 97802, 97803, 97804, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, S9452, S9470, G0270, G0271, G0108, G0109, S9140, S9141, S9455, S9460, S9465, S9449 with dx edits G0446 for 2012 87590, 87591, 87592 no dx needed, 87800, 87801, 87850 with dx edits Done at delivery; part of inpatient stay 92586, 92587 with dx edits; 92558 1220F, 3351F, 3352F, 3353F, 3354F with visit 3511F, 4293F V65.3 along with any other dx that does not start with V. 651.xx, V01.6, V15.85, V22.xx, V23.xx, V28.8, V28.9, V69.2, V72.3, V76.2, V74.5 V72.19 Page 4 of 19
Recommendation ASO. Based on the 19 Hepatitis B Virus Infection, Screening covered in full for women covered in full for women 80055 and 87340 no dx needed; 86704, 86705, 86706, 86707, 87341, 87350, 87515, 87516, 87517 with dx edits 3216F, 3513F V22.xx, V23.xx, V28.8, V28.9, 651.xx 20 High Blood Pressure Screening (18 and older) Generally part of visit and not coded separately. 2000F, 3074F, 3075F, 3077F, 3078F, 3079F, G8477, G8588-91 billed with E and M code 21 HIV Screening (At Risk and All Pregnant Women) G0432, G0433, G0435, 86701, 86702, 86703 no edits needed, 86689, 87390,87391, 87534, 87535, 87536, 87537, 87538, 87539, 87901, 87903, 87904 with dx edits 651.xx, V01.6, V15.85, V22.xx, V23.xx, V28.8, V28.9, V69.2, V72.3, V76.2, V74.5, V73.89 21w 22 Counseling and screening for human immune-deficiency virus (HIV) Iron Deficiency Anemia, Prevention (At Risk 6 to 12 Month Old Babies) covered in full for all children 6 to 12 months covered in full for all children 6 to 12 months Screening is already covered for some women. No specific codes for counseling. Part of visit. Will be billed with NDC to pharmacy (script required) but paid as medical benefit Page 5 of 19
Recommendation ASO. Based on the 23 Iron Deficiency Anemia, Screening covered in full for pregnant women covered in full for pregnant women 80055, 85013, 85014, 85018, 85025, 85027, 83540 with dx edits 651.xx, V22.xx, V23.xx, V28.8, V28.9 24 Screening for cholesterol abnormalities 25 Obesity in Adults Screening and Intensive Counseling and Behavioral Interventions Screening and counseling for obesity: children covered in full for all ages covered in full for age > 6 80061, 82465, 83700, 83701, 83704, 83718, 83721, 84478 with dx edits 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 97802, 97803, 97804, G0270, G0271, G0447, S9451, S9452, S9470, S9449 with dx edits 3011F, 3048F, 3049F, 3050F, G8593 V77.91 V77.8, V85.5x, V65.3, V65.41 26 Osteoporosis in Women, Screening: 65+ / 60+ If At Risk (Includes DEXA and/or bone density testing (BMD)) Covered in full for men and women covered in full for women > 60 77078, 77080, 77081, 77082, 77083, 78350, 78351, 76977, G0130 with dx edits V82.81, V07.4, V49.81 27 Phenylketonuria, Screening Newborn 28 Rh (D) Incompatibility, Screening covered in full for pregnant women covered in full for pregnant women 84030 with dx edits, S3620 no edits needed 80055, 86901 with dx edits V77.3 V22.xx, V23.xx, V28.8, V28.9, 651.xx Page 6 of 19
Recommendation ASO. Based on the 29 Sexually Transmitted Infections, Counseling (at risk adolescents and adults) 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245 with dx edits G0445 V65.44, V65.45, V69.2 29w Counseling on sexually transmitted infections (STIs) 30 Sickle Cell Disease, Screening Newborns 31 32 33 Syphilis Infection Screening (At Risk and All Pregnant Women) Tobacco Use and Tobacco-Caused Disease, Counseling Type 2 Diabetes Mellitus in Adults, Screening with Sustained Blood Pressure Adult women only covered in full for children < 1 adults only, age > 19 covered in full covered in full for children < 1 adults only, age > 19 covered in full No specific codes. Part of visit. Part of DRG; 83020, 83021 with dx edits, S3620 no edits needed 80055, 86592, 86593, 86780 with dx edits 99406, 99407 ; G0436, G0437 83036, 82947 with dx edits 3512F 3074F, 3075F, 3077F, 3078F, 3079F, 3080F V78.2 651.xx, V01.6, V22.xx, V23.xx, V28.8, V28.9, V69.2, V74.5, V72.3x, V76.2 V77.1 33 w Screening for gestational diabetes 82950, 82951, 82952 with Dx edits V77.1, V22.xx, V23.xx 34 35 Visual Impairment in Children Younger than 5 Years, Screening; Effective 1/1/11 age expanded to age 5 and younger Discuss Chemoprevention When at High Risk for Breast Cancer covered in full for children < 4 5 covered in full for children < 4 5 99173 with dx edits; applicable to ITS Home claims only since code bundles for local business Generally part of visit and not coded separately. V72.0, V80.2, 368.00-368.03, 378.00-378.08, 378.10-378.18 Page 7 of 19
Recommendation 36 Daily Supplement of Folic Acid covered in full for all women up to age 63 covered in full for all women up to age 63 ASO. Based on the Will be billed with NDC to pharmacy (script required) but paid as medical benefit 37 PSA Testing covered in full for all men >= 30 NA - see comment below 84152, 84153, 84154 with dx edits, G0102, G0103 no edits needed V76.44, V70.0 V72.62 38 Routine OB/GYN Visit 39 Routine Physical and/or Counseling 39w Well woman visits - Wellness preventive care 2 exams per year (Facets will do this.) 1 exam annually covered in full (Facets will do this.) NA - see comment below Age 19-21 covered in full. 99384, 99385, 99386, 99387, 99394, 99395, 99396, 99397 with dx edits, Q0091, Q0111, G0101, S0610, S0612, S0613 no edits needed 99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397, 99460, 99461, 99463, G0402, 99401, 99402, 99403, 99404, 99406, 99407, 99408, 99409 with dx edits; G0438, G0439 Same codes as already covered under existing preventive guidelines. V72.3-V72.32, V76.2, V76.47, V25.40-V25.49 Page 8 of 19
Recommendation ASO. Based on the 40 Routine Vision Exam 1 every 2 yrs; 1 per yr for under 14 with diagnosed refractive error covered in full. NA - see comment below 41 Well Child Visits 42 Well Child Vaccines and Vaccine Administration, Lab and Developmental Testing S0620, S0621, 92002, 92004, 92012, 92014, 92015 with dx edits Refer to Well Child Guidelines Per ACIP/AAP/ USPSTF recommendations - refer to Well Child Guidelines for vaccines 367.0-367.4, V72.0, V20.2 43 Adult Immunizations and Vaccine Administration adults > 19 years of age covered in full no routine immunizations covered OON adults > 19 years of age covered in full Per ACIP guidelines; 90632, 90636, 90649, 90650, 90669, 90670, 90696, 90698, 90701, 90703, 90705, 90706, 90707, 90708, 90710, 90714, 90715, 90716, 90718, 90732, 90733, 90734, 90736, 90740, 90746, 90747, 90471, 90472, 90473, 90474, G0009, G0010 Page 9 of 19
Recommendation ASO. Based on the 44 Flu Vaccine and Vaccine Administration covered in full for all 45 46 w Lab work ordered as part of a routine physical or routine ob/gyn visit Screening and counseling for interpersonal and domestic violence Lab tests within 30 days of routine physical covered in full 90654, 90655, 90656, 90657, 90658, 90659, 90660, 90661, 90662, 90460, 90461, 90471, 90472, 90473, 90474, G0008, Q2035, Q2036, Q2037, Q2038, Q2039 No specific codes. Part of visit. DX to match that of routine physical OR V72.62 Page 10 of 19
Recommendation ASO. Based on the 47 w Contraceptive methods and counseling 58600, 58605, 58611, 58615, 58670, 58671 for surgical procedures. 57170, 58300, 58565, 58615, 58661, 58720, A4261, A4266, A4268 (NC), A4269 (NC), J1050, J1055 deleted 2013, J7300, J7301, J7302, J7303, J7304, J7306, J7307, S4981, S4989, S4993 (NSF) 11981 and 11983 with dx code that starts with a V. Contraceptives thru Medco 48 Screening for Hepatitis C Virus Infection in Adults age 18 and older covered in full 86803, 86804 49 Prevention of Falls in Community- Dwelling Older Adults; exercise or physical therapy age 65 and older covered in full 97001, 97002, 97039, 97110, 97112, 97113, 97116, 97139, 97150, 97350, G0157, G0159 Refer to codes for fall prevention tab at the end of this document. Page 11 of 19
Recommendation ASO. Based on the 50 Prevention of Falls in Community- Dwelling Older Adults; vitamin D age 65 and older covered in full Paid under pharmacy benefit. Rx is required. 51 Skin Cancer behavioral counseling Age 10 to 24 covered in full Generally part of visit and not coded separately. 52 Medications to reduce the risk of breast cancer (Tomoxifen and Raloxifene) Age >35 Paid under pharmacy benefit. Rx is required. Prior approval is required. Page 12 of 19
Corporate Standard Recommended Implementation Strategy PT visits accumulate toward PT limits Provider determines if individual is considered high risk Initial office visit and subsequent PT visits for fall prevention covered at no cost share Community-dwelling means that the individual is not in an assisted living facility, nursing home, skilled nursing facility or an inpatient at a hospital. CORPORATE STANDARD CODING FOR FALL PREVENTION RECOMMENDATION Procedure codes Code Definition 97001 PT evaluation 97002 PT re-evaluation 97039 Unlisted PT modality 97110 Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of 97112 movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and standing activities 97113 Therapeutic procedure, 1 or more areas, each 15 minutes; aquatic therapy with therapeutic exercises 97116 Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing) 97139 Unlisted therapeutic procedure 97150 Non discript 97530 Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes G0157 Services performed by qualified physical therapist assistant in the home health or hospice setting, each 15 min G0159 Services performed by a qualified physical therapist, in the home health setting, in the establishment or delivery of a safe and effective PT maintenance program, each 15 min
ICD9 Diagnosis codes Code Definition V15.88 History of falls/at risk for falling 780.4 Dizziness and giddiness 780.71 Chronic fatigue syndrome 780.79 Other malaise and fatigue 781.2 Abnormality of gait 781.3 Lack of coordination 251.1 Other specified hypoglycemia 251.2 Hypoglycemia, unspecified 280 Iron deficiency anemia secondary to blood loss (chronic) 280.1 Iron deficiency anemia secondary to inadequate dietary iron intake 280.8 Other specified iron deficiency anemias 281 Pernicious anemia 281.1 Other vitamin B12 deficiency anemia 281.2 Folate deficiency anemia 281.3 Other specified megaloblastic anemias NOC 281.4 Protein deficiency anemia 281.8 Anemia associated with other specified nutritional deficiency 282 Hereditary spherocytosis 282.1 Hereditary eliptoctyosis 282.2 Anemias due to disorders of glutathione metabolism 282.3 Other hemolytic anemias due to enzyme deficiency 282.41 Sickle-cell thalassemia without crisis 282.42 Sickle-cell thalassemia with crisis 282.43 Alpha thalassemia 282.44 Beta thalassemia 282.45 Delta-beta thalassemia 282.46 Thalassemia minor 282.47 Hemoglobin E-beta thalassemia 282.49 Other thalassemia
282.5 Sickle-cell trait 282.6 Sickle-cell disease, unspecified 282.61 Hb-SS disease without crisis 282.62 Hb-SS disease with crisis 282.63 Sickle-cell/Hb-C disease without crisis 282.64 Sickle-cell/Hb-C disease with crisis 282.68 Other sickle-cell disease without crisis 282.69 Other sickle-cell disease with crisis 282.7 Other hemoglobinopathies 282.8 Other specified hereditary hemolytic anemias 283 Autoimmune hemolytic anemias 283.1 Non-autoimmune hemolytic anemias, unspecified 283.11 Hemolytic-uremic syndrome 283.19 Other non-autoimmune hemolytic anemias 283.2 Hemoglobinuria due to hemolysis from external causes 284.01 Constitutional red blood cell aplasia 284.09 Other constitutional aplastic anemia 284.11 Antineoplastic chemotherapy induced pancytopenia 284.12 Other drug-induced pancytopenia 284.19 Other pancytopenia 284.2 Myelophthisis 284.4 Thalassemia, unspecified 284.81 Red cell aplasia (acquired) (adult) (with thymoma) 284.89 Other specified aplastic anemias 285 Sideroblastic anemia 285.1 Acute posthemorrhagic anemia 285.21 Anemia in chronic kidney disease 285.22 Anemia in neoplastic disease 285.29 Anemial of other chronic disease 285.3 Antineoplastic chemotherapy induced anemia 285.8 Other specified anemias 286 Congenital factor VIII disorder 286.1 Congenital factor IX disorder
286.2 Congenital factor XI deficiency 286.3 Congenital deficiency of other clotting factors 286.4 von Willebrand's disease 286.52 Acquired hemophilia 286.53 Antiphospholipid antibody with hemorrhagic disorder 286.59 Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors 286.6 Defibrination syndrome 286.7 Acquired coagulation factor deficiency 286.9 Other and unspecified coagulation defects 287 Allergic purpura 287.1 Qualitative platelet defects 287.2 Other nonthrombocytopenic purpuras 287.3 Primary thrombocytopenia, unspecified 287.31 Immune thrombocytopenic purpura 287.32 Evan's syndrome 287.33 Congenital and hereditary thrombocytopenic purpura 287.39 Other primary thrombocytopenia 287.41 Posttransfusion purpura 287.49 Other secondary thrombocytopenia 287.5 Thrombocytopenia, unspecified 287.8 Other specified hemorrhagic conditions 287.9 Unspecified hemorrhagic conditions 288 Neutropenia, unspecified 288.01 Congenital neutropenia 288.02 Cyclic neutropenia 288.03 Drug induced neutropenia 288.04 Neutropenia due to infection 288.09 Other neutropenia 288.1 Functional disorders of polymorphonuclear neutrophils 288.2 Genetic anomalies of leukoctyes 288.3 Eosiniphilia 288.4 Hemophagocytic syndromes
293 Delirium due to conditions classified elsewhere 293.1 Subacute delirium 386 Meniere's disease, unspecified 386.01 Active Meniere's disease, cochleovestibular 386.02 Active Meniere's disease, cochlear 386.03 Active Meniere's disease, vestibular 386.04 Inactive Meniere's disease 386.1 Peripheral vertigo, unspecified 386.11 Benign paroxysmal positional vertigo 386.12 Vestibular neuronitis 386.19 Other peripheral vertigo 386.2 Vertigo of central origin 386.3 Labyrinthitis, unspecified 386.31 Serous labyrinthitis 386.32 Circumscribed labyrinthitis 386.33 Suppurative labyrinthitis 386.35 Viral labyrinthitis 386.4 Labyrinthine fistula, unspecified 386.41 Round window fistula 386.42 Oval window fistula 386.43 Semicircular canal fistula 386.48 Labyrinthine fistula of combined sites 386.5 Labyrinthine dysfunction, unspecified 386.51 Hyperactive labyrinth, unilateral 386.52 Hyperactive labyrinth, bilateral 386.53 Hypoactive labyrinth, unilateral 386.54 Hypoactive labyrinth, bilateral 386.55 Loss of labyrinthine reactivity, unilateral 386.56 Loss of labyrinthine reactivity, bilateral 386.8 Other disorders of labyrinth 386.9 Unspecified verginous syndromes and labyrinthine disorders 427 Paroxysmal supraventricular tachycardia 427.1 Paroxysmal ventricular tachycardia
427.2 Paroxysmal tachycardia, unspecified 427.31 Atrial fibrillation 427.32 Atrial flutter 427.41 Ventricular fibrillation 427.42 Ventricular flutter 427.5 Cardiac arrest 427.6 Premature beats, unspecified 427.61 Supraventricular premature beats 427.69 Other premature beats 427.81 Sinoatrial node dysfunction 427.82 Other specified cardiac dysrhythmia 427.9 Cardiac dysrhythmia, unspecified 458 Orthostatic hypotension 458.1 Chronic hypotension 458.21 Hypotension of hemodialysis 458.29 Other iatrogenic hypotension 458.8 Other specified hypotension 458.9 Hypotension, unspecified 719.75 Difficulty in walking, pelvic region and thigh 719.76 Difficulty in walking, lower leg 719.77 Difficulty in walking, ankle and foot 719.78 Difficulty in walking, other specified sites 719.79 Difficulty in walking, multiple sites 733 Osteoporosis, unspecified 733.01 Senile osteoporosis 733.02 Idiopathic osteoporosis 733.03 Disuse osteoporosis 733.09 Other osteoporosis 733.1 Pathologic fracture, unspecified site 733.13 Pathologic fracture of vertebrae 733.14 Pathologic fracture of neck of femur 733.15 Pathologic fracture of other specified part of femur 733.16 Pathologic fracture of tibia or fibula
780.2 Syncope and collapse 796.3 Nonspecific low blood pressure reading