Preventive Health Guidelines for Providers Sanford Health Plan has adopted the preventive care benefits as outlined under The Patient Protection and Affordable Care Act. Members can refer to their Summary of Plan Benefits for specific Preventive Health coverage. Annual preventive services do not need to be scheduled 12 months apart. Members may have their preventive services one time per calendar year. For example, if the services were done July last year, it is ok to schedule them before July this year. Birth through 3 Years Well Care Visit: Coverage provided for inpatient newborns; visits at 3-5 days old; and at 1, 2, 4, 6, 9, 12, 15, 18, 24 and 30 months old. Visits include: health advice and information about development, behavior, safety/injury prevention, sleep positions, feeding, diet, daily care, physical activity and dental care. During the visit, your child may receive immunizations and screenings based on your healthcare practitioner s recommendations. Preventive Care for Newborns: State/Federal mandated neonatal screening tests Hearing screening One screening between ages 1 18 months. Immunizations: See Childhood Immunization Schedule www.cdc.gov/vaccines OR Request printed copy of the immunization schedule Member Services - (605) 328-6800 or 1-800-752-5863 NOTE CPT & HCPCS codes for general administration of vaccine include: 90460-90468 90471-90474 G0192 As indicated for specific vaccines. ICD-9 Diagnosis V20.0-V20.2, V20.31-V20.32, V70.0, V72.62, V79.3 Influenza: V04.81 CPT Procedure 99381-99382, 99391-99392, 99461 HCPCS Procedure G0438, G0439 DTP / DT / Td / DTaP 90698, 90700, 90702, 90703, 90719, 90720, 90721, 90723, 90698 Hepatitis A 90633 Hepatitis B 90723, 90740, 90744, 90747, 90748, Q3021 Hib 90644, 90645-90648, 90698, 90720, 90721, 90748 Influenza 90630, 90654, 90655, 90656, 90657, 90658, 90660, 90661, 90662, 90664, 90672, 90673, 90685, 90686 IPV 90698, 90712, 90713, 90723 Hepatitis B G0010, Q3021, Q3023 Influenza G0008 Influenza Q2034-Q2039 Revenue
MMR 90704-90708, 90710 90669, 90670, 90732 Rotavirus 90680, 90681 Varicella 90710, 90716 G0009 Screenings: Weight, Length and Head Circumference: At every visit. Developmental: In office screening at 9, 18, and 30 months with a V20.2-V20.2, 96110 standardized validated tool. V20.31-V20.32, Autism: In office screening at 18 and 24 months with a standardized validated tool. V70.0,V79.3 V20.2-V20.2, V20.31-V20.32, V70.0,V79.3 Vision: In office screen as part of preventive exam which includes alignment/cover test and visual acuity (Snellen) when age appropriate. Hearing: In office assessment as part of preventive exam. Dental: This includes regular oral health screenings and referral to a dentist at the appropriate age. After 6 months of age, your healthcare practitioner may prescribe fluoride if necessary. Hemoglobin Or hematocrit (Hgb/Hct): One Hemoglobin OR One Hematocrit between 9-15 months Cholesterol Test: A baseline Lipid Profile if at high risk, as determined by your healthcare practitioner. Two are allowed between the ages of 0 and 18 years. Lead screenings: One screening test at 12 months and one at 24 months Tuberculosis Screening: As needed if screening questions are positive V20.0-V20.2, V70.0, V70.9, V72.62 272.0-272.4, V17.3, V17.4, V18.1, V20.0- V20.2, V70.0, V70.9, V72.31-V72.32, V72.62, V72.81, V76.10-V76.19, V76.2, V76.41, V76.44, V76.49- V76.51, V77.91, V82.9 V20.2-V20.2, V20.31-V20.32, V70.0,V79.3 96110 85013, 85014, 85018 80061, 82465, 83700, 83701, 83704, 83718, 83719, 83721 83655 86580
Ages 4 To 17 Well Care Visit: Once a year for children ages 4 to 17. Visits include: age and gender appropriate health advice and information about dental care, exercise and physical activity, diet and nutrition, counseling for obesity, sun exposure and safety/injury prevention. When appropriate, alcohol, sexual behavior/stds, smoking and suicide prevention is also addressed. During the visit, your child may receive immunizations and screenings based on your healthcare practitioner s recommendation. Immunizations: See Childhood Immunization Schedule www.cdc.gov/vaccines OR Request printed copy of the immunization schedule Member Services - (605) 328-6800 or 1-800-752-5863 NOTE: HPV series is typically given at ages 11-12 to both males and females, but may be given from ages 9-26. NOTE CPT & HCPCS codes for general administration of vaccine include: 90460-90468 90471-90474 G0192 As indicated for specific vaccines. ICD-9 Diagnosis V23.49, V70.0, V72.3, V72.31, V72.62, V74.5, V76.10-V76.19, V76.2, V76.41, V76.44, V76.49, V76.50, V79.3 Influenza: V04.81 CPT Procedure 99382-99384, 99392-99394 DTP / DT / Td / DTaP / Tdap 90696, 90698, 90700, 90702, 90703, 90714, 90715, 90719, 90720-90721, 90723 Hepatitis A 90633 Hepatitis B 90723, 90740, 90743, 90744, 90747, 90748 Influenza 90630, 90654, 90656, 90658, 90660, 90661, 90662, 90664, 90672, 90673, 90686 IPV 90696, 90698, 90712, 90713, 90723 Meningococcal 90733-90734 MMR 90704-90708, 90710 90669, 90670, 90732 HCPCS Procedure G0438, G0439 Hepatitis B G0010, Q3021 Influenza G0008 Influenza Q2034-Q2039 G0009 Revenue Varicella 90710, 90716 HPV S0195
90649, 90650 Screenings: Height/Weight/BMI/Blood Pressure: At every Well Care Visit. At age 6 and over, review of Body Mass Index (BMI), a tool used to screen for obesity, with your healthcare practitioner. Cholesterol Test: A baseline Lipid Profile if at high risk, as determined by your healthcare practitioner. Two are allowed between the ages of 0 and 18 years. Vision: In office screen as part of preventive exam which includes alignment/cover test and visual acuity (Snellen) when age appropriate. Hearing: In office assessment as part of preventive exam. Screening audiograms may be performed at ages 4, 5, 6, 8, and 10 if needed. Dental: This includes regular oral health screenings and referral to a dentist at the appropriate age. After 6 months of age, your healthcare practitioner may prescribe fluoride if necessary. Sexually Transmitted Disease (STD): All sexually active adolescents should be counseled and screened for STDs, including Chlamydia, gonorrhea, syphilis and HIV. Tuberculosis Screening: As needed if screening questions are positive. Screening Depression: Starting at age 12 for major depression 272.0-272.4, V17.3, V17.4, V18.1, V70.0, V70.9, V72.31- V72.32, V72.62, V72.81, V76.10- V76.19, V76.2, V77.91, V82.9 80061, 82465, 83700, 83701, 83704, 83718, 83719, 83721 In office assessment included as part of the well care visit fee and not billed separately. Audiograms: V72.19, V72.11 Audiograms: 92550-92588 Audiograms: V5008 Counseling is included as part of the well care visit fee and not billed separately. V69.2,V70.0, V72.31, V73.88, V73.98, V74.5, V74.9, V75.9, V76.2, V76.47, V02.9, V65.45 V69.2, V70.0, V72.31, V72.62, V73.98, V74.5, V74.9, V75.9, V76.2, V76.47, V69.2 V69.2, V02.9, V70.0, V73.89, V74.5, V75.9, V76.2, V76.47 V70.0,, V72.31, V72.62,V74.5, V65.45, V76.47, V74.9, V76.2, V02.9 86631, 87110, 87270, 87320, 87490-87492, 87810 87590-87592, 87850 86701-86703 87390-87391 86592-86593 86580 G0432, G0433, G0435
when systems are in place to ensure accurate diagnosis, psychotherapy, & follow up. Ages 18 to 59 Preventive Exam (Physical): Once a year for adults ages 18-59. Visits include: health advice and counseling about dental care, exercise and physical activity, diet and nutrition, obesity, sun exposure, safety/injury prevention, alcohol, sexual behavior/stds, Medical education and smoking. During the visit, you may receive immunizations and screenings based on your healthcare practitioner s recommendation. Immunizations: See Adult Immunization Schedule www.cdc.gov/vaccines OR Request printed copy of the immunization schedule Member Services - (605) 328-6800 or 1-800-752-5863 NOTE: HPV series is typically given at ages 11-12 to both males and females, but may be given from ages 9-26. NOTE: Pregnant women Tdap is indicated once per pregnancy, in accordance with CDC guidelines. NOTE CPT & HCPCS codes for general administration of vaccine include: 90460-90468 90471-90474 G0192 As indicated for specific vaccines. Screenings: For Men & Women Height/Weight/BMI/Blood Pressure: At every Wellness Exam. Review your Body Mass Index (BMI), a tool used to screen for obesity, with your healthcare practitioner. Cholesterol Test: Between the ages 18 and 24 one Lipid Profile ICD-9 Diagnosis V23.49, V70.0, V72.3, V72.31, V72.62, V74.5, V76.10-V76.19, V76.2, V76.41, V76.44, V76.49, V76.50, V79.3 Influenza: V04.81 Shingles age 50+:053.9 272.0-272.4, V17.3, V17.4, V18.1, V70.0, CPT Procedure 99201-99215, 99241-99245, 99385-99386 Hepatitis B 90723, 90740, 90747, 90748, 90636 Influenza 90630, 90654, 90656, 90658, 90660, 90661, 90662, 90664, 90672, 90673, 90686 Meningococcal 90733-90734 90669, 90670, 90732 DTP / DT / Td / DTaP / Tdap 90698, 90703, 90714, 90715, 90719,, 90720, 90721, 90723 Varicella 90710, 90716 Zostavax Vaccine age 50+: 90736 HPV 90649, 90650 HCPCS Procedure Hepatitis B G0010, Q3022-Q3023 Influenza G0008 Influenza Q2034-Q2039 G0009 80061, 82465, 83700, 83701, 83704, 83718, Revenue
Between ages 25 and 44 one Lipid Profile every 5 years Age 45 and older one Lipid Profile every year Counseling for Healthy Diet: In office assessment and counseling for members with hyperlipidemia and other known risk factors for cardiovascular disease and diet related chronic disease. Diabetes Screening: Screen for type 2 diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 (fasting blood glucose or basic metabolic panel (see above)). Colorectal Screening: Between ages 40 and 49 - yearly stool for occult blood by fecal hemoglobin Age 50 and older colonoscopy every 10 years or stool for occult blood every year or flexible sigmoidoscopy every 5 years. V70.9, V72.31- V72.32, V72.62, V72.81, V76.10- V76.19, V76.2, V77.91, V82.9 V70.0, V72.31, V72.62, V77.1 V70.0, V70.9, V72.3, V76.10-V76.19, V76.2, V76.3, 83719, 83721 Fasting Blood Glucose: 82947, 82948, 83036 82270, 82274 Flexible Sigmoidoscopy: 45300-45345 G0328 Flexible Sigmoidoscopy: G0104 RV300-RV319 Colonoscopy: 44388-44397, 45355-45392 Colonoscopy: G0105, G0121, G0120 Hemoglobin or hematocrit (Hgb/Hct): One hemoglobin or one hematocrit every year. Sexually Transmitted Disease (STD): For all adults at risk and includes: Chlamydia, gonorrhea, syphilis and HIV. V70.0, V70.9, V76.2, V76.3, V69.2, V70.0, V72.31, V73.88, V73.98, V74.5, V74.9, V75.9, V76.2, V76.47, V02.9, V65.45 V69.2, V70.0, V72.31, V72.62, V73.98, V74.5, V74.9, V75.9, V76.2, V76.47, V69.2 V69.2, V02.9, V70.0, 85013, 85014, 85018 86631, 87110, 87270, 87320, 87490-87492, 87810 87590-87592, 87850 86701-86703 87390-87391 G0432, G0433, G0435
Depression Screening: Screen for major depression when systems are in place to ensure accurate diagnosis, psychotherapy, and follow up. V73.89, V74.5, V75.9, V76.2, V76.47 V70.0,, V72.31, V72.62,V74.5, V65.45, V76.47, V74.9, V76.2, V02.9 86592-86593 For Women Mammogram: One screening per year beginning at age 40. 77051-77052, 77055- BRCA Screening: Women with a family history (breast or ovarian cancer) associated with increased risk for harmful mutations in BRCA1 or BRCA2 should be referred for genetic counseling regarding BRCA testing. (Limit 1 per lifetime) Counseling women at high risk for breast cancer: Counseling for chemoprevention of breast cancer (as part of the annual preventive health examination). Pap Smear Age 21 29: Every 3 years. Age 30 65: Every 3 years; or every 5 years if HPV test is also performed. V10.3, V10.43, V16.3, V16.41, V26.33 V70.0, V70.9, V72.31,V72.62, V76.2, V76.47, V76.49 HPV Testing: HPV testing for women over 30 years old. 079.4, 795.01, 795.05, 795.09, v73.81, V69.2 For Men Prostate Specific Antigen (PSA): one test per year beginning at age 50. Additional Covered Benefits: Basic Metabolic Panel: One per year and should include the following: Calcium, Carbon Dioxide, Chloride, Creatinine, Glucose, Potassium, Sodium, Urea Nitrogen (BUN). V16.42, V70.0, V70.9, V72.62, V76.44, V84.03 V70.0, V70.9, V72.3, V72.31, V72.62, V76.10- V76.19, V76.2, G0202, G0204, G0206 RV401, RV403 77057 96040 S0265 88141-88167, 88174-88175 83892, 83894, 83903, 83912, 87320,87620-87622, 88141 84152-84154 G0103 G0101, G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091 RV923 80048 RV300-RV319
Ages 60 + ICD-9 Diagnosis CPT Procedure HCPCS Procedure Revenue Preventive Exam (Physical): Once a year for adults age 60 years +. Visits should include: health advice and counseling about dental care, exercise and physical activity, diet and nutrition, obesity, sun exposure, safety/injury prevention, alcohol, sexual behavior/stds and smoking. During the visit, you may receive immunizations and screenings based on your healthcare practitioner s judgment. Immunizations: See Adult Immunization Schedule www.cdc.gov/vaccines OR Request printed copy of the immunization schedule Member Services - (605) 328-6800 or (800) 752-5863 NOTE CPT & HCPCS codes for general administration of vaccine include: 90460-90468 90471-90474 G0192 As indicated for specific vaccines. Screenings: For Men & Women Height/Weight/BMI/Blood Pressure: At every Wellness Exam. Review your Body Mass Index (BMI), a tool used to screen for obesity, with your healthcare practitioner. Cholesterol Test: One Lipid Profile per year. V23.49, V70.0, V72.3, V74.5, V76.10-V76.19, V76.2, V76.49, V76.50, V79.3 Influenza: V04.81 Zostavax - age 50+: 053.9 272.0-272.4, V17.3, V17.4, V18.1, V70.0, V70.9, V72.31-V72.32, V72.62, V72.81, V76.10-V76.19, V76.2, V77.91, V82.9 99201-99215, 99241-99245, 99386-99387 Hepatitis B 90723, 90740, 90747, 90748, 90636 Influenza 90630, 90654-90664, 90672-90673; 90685-90686 Meningococcal 90733-90734 90669, 90670, 90732 Td, Tdap Vaccine : 90703, 90714, 90715, 90719 Varicella 90710, 90716 Zostavax age 50+: 90736 Hepatitis B G0010, Q3022-Q3023 Influenza G0008 Influenza Q2034-Q2039 G0009 80061, 82465, 83700, 83701, 83704, 83718, 83719, 83721
Counseling for Healthy Diet: In office assessment and counseling for members with hyperlipidemia and other known risk factors for cardiovascular disease and diet related chronic disease. Diabetes Screening: Screen for type 2 diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 (fasting blood glucose or basic metabolic panel (see above)). Colorectal Screening: One colonoscopy every 10 years or stool for occult blood every year or flexible sigmoidoscopy every 5 years. V70.0, V77.1 V70.0, V70.9, V72.3, V76.10-V76.19, V76.2, V76.3, Fasting Blood Glucose: 82947, 82948, 83036 82270, 82274 Flexible Sigmoidoscopy: 45300-45345 G0328 Flexible Sigmoidoscopy: G0104 RV300-RV319 Colonoscopy: 44388-44397, 45355-45392 Colonoscopy: G0105, G0121, G0120 Hemoglobin Or hematocrit (Hgb/Hct): One Hemoglobin OR One Hematocrit every year. Screening for Depression: Screen for major depression when systems are in place to ensure accurate diagnosis, psychotherapy, and follow up. Sexually Transmitted Disease (STD): For all adults at risk and includes: Chlamydia, gonorrhea, syphilis and HIV. V70.0, V70.9, V72.31, V72.62, V76.2, V76.3, V69.2, V70.0, V72.31, V72.31, V72.62, V73.88, V73.98, V74.5, V74.9, V75.9, V76.2, V76.47, V02.9, V65.45 V69.2, V70.0, V73.98, V74.5, V74.9, V75.9, V76.2, V76.47, V69.2 V69.2, V02.9, V70.0, V73.89, V74.5, V75.9, V76.2, V76.47 85013, 85014, 85018 86631, 87110, 87270, 87320, 87490-87492, 87810 87590-87592, 87850 86701-86703 87390-87391 G0432, G0433, G0435
For Women Osteoporosis Screening: For women 65 and older or beginning at age 60 if increased risk. (Limit 1 per lifetime) V70.0,V72.31, V72.62,V74.5, V65.45, V76.47, V74.9, V76.2, V02.9 V17.81, V49.81, V70.0, V82.81 86592-86593 76977, 77078, 77080, 77081 Mammogram: One screening per year. 77051-77052, 77055-77057 G0202, G0204, G0206 RV401, RV403 BRCA Screening: Women with a family history (breast or ovarian cancer) associated with increased risk for harmful mutations in BRCA1 or BRCA2 should be referred for genetic counseling regarding BRCA testing. (Limit 1 per lifetime) V10.3, V10.43, V16.3, V16.41, V26.33 96040 S0265 Counseling women at high risk for breast cancer: Counseling for chemoprevention of breast cancer (as part of the annual preventive health examination). Pap Smear: Age 30 65 every 3 years; or every 5 years if HPV test is also performed. For Men Abdominal Aortic Aneurysm Screening: For men ages 65 to 75 years who have ever smoked. (Limit 1 per lifetime) Additional Covered Benefits: Basic Metabolic Panel: One per year and should include the following: Calcium, Carbon Dioxide, Chloride, Creatinine, Glucose, Potassium, Sodium, Urea Nitrogen (BUN). For Men: Prostate Specific Antigen: For men: one test per year V70.0, V70.9, V72.31,V72.62, V76.2, V76.47, V76.49 V15.82, V70.0, V70.8, V72.62, V81.2, V82.89 V70.0, V70.9, V72.3, V76.10-V76.19, V76.2, V16.42, V70.0, V70.9, V72.62, V76.44, V84.03 G0130 88141-88167, 88174-88175 76700, 76705, 76770, 76775 G0101, G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091 G0389 RV923 80048 RV300-RV319 84152-84154 G0103 *Sources: Adopted from Guide to Clinical Preventive Services, 2014: Recommendations of the U.S. Preventive Services Task Force. June 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/guide/index.html, CDC, American Cancer Society, Bright Futures at Georgetown University, Sanford Health Plan Physician Quality Committee. Revised: 7/2014