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 76707 Ultrasound B-scan and/or real time with image documentation; for adominal aortic aneurysm (AAA) screening Z13.6 Colorectal Cancer 99201-99205 Z12.11 Z12.12 Z80.0 Z83.71 Z84.81 S0285 Colonoscopy consultation performed prior to a screening colonoscopy procedure G0104 G0105 G0121 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 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 Updated on 03/06/2017 Preventive Health - Men - Coding Guidelines Page 1
Colorectal Cancer (con't) 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 Z12.11 Z12.12 Z80.0 Z83.71 Z84.81 45398 with band ligation(s) (eg, hemorrhoids) 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 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 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 Type 2 Diabetes Mellitus 82947 Glucose; quantitative, blood (except reagent strip) Z13.1 83036 Hemoglobin; glycosylated (A1C) Updated on 03/06/2017 Preventive Health - Men - Coding Guidelines Page 2
High Blood Pressure 99201-99205 Z01.30 Z01.31 Z13.6 HIV 86689 Antibody; HTLV or HIV antibody, confirmatory test (eg, Western Blot) Z11.4 Z20.6 86701 Antibody; HIV-1 86702 Antibody; HIV-2 86703 Antibody; HIV-1 and HIV-2, single result 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 87390 (eff 1/1/2013) 87391 (eff 1/1/2013) 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 G0432 G04 G0435 G0475 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 Infectious agent antigen detection by rapid antibody test of oral mucosa transudate, HIV-1 or HIV-2, screening HIV antigen/antibody, combination assay, screening Lipid Disorders 80061 Lipid panel 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) Screening for hepatitis C virus (HCV) 86780 Antibody; Treponema pallidum G0472 Hepatitis C antibody screening for individual at high risk and other covered indication(s) Z11.3 Z72.51 Z72.52 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) Updated on 03/06/2017 Preventive Health - Men - Coding Guidelines Page 3
Aspirin for the prevention of Cardiovascular disease (CVD) Covered through HMSA's Pharmacy Benefit Manager with prescription Alcohol Misuse 99201-99205 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 timebased. Depression 99201-99205 Z13.89 96127 Brief emotional/behavioral assessment (eg, depression inventory, attentiondeficit/hyperactivity disorder [ADHD] scale, with scoring and documentation, per standardized instrument Tobacco Use and Tobacco Caused Disease 99201-99205 Z71.6 Z87.891 F17.200 F17.201 F17.210 F17.211 F17.220 F17.221 F17.290 F17.291 Obesity 99201-99205 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 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). Updated on 03/06/2017 Preventive Health - Men - Coding Guidelines Page 4
Obesity con't 97802 Medical nutrition therapy; initial assessment and intervention, individual, face-toface 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 99201-99205 Sexually Transmitted Infections (STI) Nutritional counseling, dietitian visit 97802 Medical nutrition therapy; initial assessment and intervention, individual, face-toface 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 99201-99205 Nutrition classes, nonphysician provider, per session Nutritional counseling, dietitian visit Z04.6 Z13.1 E66.01-E66.1 E66.8-E66.9 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 E78.00-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 99401-99404 99411-99412 Prevention of falls 99201-99205 Counseling. Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual or individuals in a group setting (separate procedure). Z91.81 Updated on 03/06/2017 Preventive Health - Men - Coding Guidelines Page 5
Vitamin D supplementation for the prevention of falls Covered through HMSA's Pharmacy Benefit Manager with prescription Skin cancer 99201-99205 Z12.83 Z91.89 Lung Cancer G0297 Low-dose computed tomography for lung cancer screening. Z12.2 Updated on 03/06/2017 Preventive Health - Men - Coding Guidelines Page 6