Description 
The Federal Patient Protection and Preventive Care Act (PPACA) was passed by Congress and signed into law by the president in March 2010. The preventive services component of the law became effective Sept. 23, 2010. A component of the law was a requirement that all “non-grandfathered” health insurance plans are required to cover those preventive medicine services given an “A” or “B” recommendation by the U.S. Preventive Services Task Force (USPSTF).

Plans are not required to provide coverage for the preventive services if they are delivered by out-of-network providers.

Task Force recommendations are graded on a five-point scale (A – E), reflecting the strength of evidence in support of the intervention. Grade A: There is good evidence to support the recommendation that the condition be specifically considered in a periodic health examination. Grade B: There is fair evidence to support the recommendation that the condition be specifically considered in a periodic health examination. Grade C: There is insufficient evidence to recommend for or against the inclusion of the condition in a periodic health examination, but recommendations may be made on other grounds. Grade D: There is fair evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination. Grade E: There is good evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.

Those preventive medicine services listed as Grade A & B recommendations are covered without cost sharing (i.e., deductible, coinsurance or copayment) by health plans for appropriate preventive care services provided by an in-network provider. If the primary purpose for the office visit is for other than Grade A or B USPSTF preventive care services, deductible, coinsurance or copayment may be applied.

Services are typically included as part of a normal wellness visit; the appropriate office visit code should be used. Evaluation and Management codes for preventive services 99381 – 99397 will always be considered preventive. CPT codes 99401 – 99404, when used to designate a preventive service, must have the applicable wellness/preventive diagnosis code as the primary reason for the visit.

When the primary purpose of the service is the delivery of an evidence-based service in accordance with a U.S. Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’.

The correct coding as listed for both ICD-9 and CPT or HCPCS codes in this summary is also required along with Modifier 33. CPT Codes Copyright © 2011 American Medical Association.

Subject to change as regulations and further clarifications are received.

NOTE: THIS POLICY APPLIES ONLY TO NON-GRANDFATHERED PLANS.

Policy: 
BACTERIURIA, SCREENING IN PREGNANT WOMEN

USPSTF Recommendation

The USPSTF recommends screening for asymptomatic bacteriuria with urine culture for pregnant women at 12 to 16 weeks gestation or at the first prenatal visit, if later. (Grade A)

 

CPT Code:

CPT 87086

 

ICD-9 Codes:

V22.0 – V22.2 — Prenatal Visits

V23.0 – V23.9 — Prenatal visits for patients with high risk pregnancies

 

ICD-10 Codes:

Z331

Z34 – Z3493

O0900 – O0933 

 

BRCA TESTING, RISK ASSESSMENT GENETIC COUNSELING/TESTING

USPSTF RECOMMENDATION

The USPSTF recommends that (Grade B) 1)primary care providers screen women who have family members with breast, ovarian, tubal or peritoneal cancer with one of several screening tools designed to identify if family history may be associated with an increased risk for potentially harmful mutations in breast cancer susceptibility genes (BRCA1 or BRCA2). 2) Women with positive screening results should receive genetic counseling and 3) if indicated after counseling, BRCA testing. Examples of screening tools include, but are not limited to: Ontario Family Health Assessment tool, Manchester Scoring System, Referral Screening tool or the Pedigree Assessment tool.

 

CPT/HCPCS Codes:

CPT 99385 – 99387

CPT 99395 – 99397

CPT 81211 – 81217

CPT 81162

CPT 96040

HCPCS S0265

 

ICD-9 Codes:

V16.3 — Family history of breast cancer

V16.40 — Family history of malignant neoplasm, unspecified genital organ

V16.41 — Family history of ovarian cancer

V26.33 — Genetic counseling

 

ICD-10 Codes:

Z803

Z8049

Z8041

Z315

 

BREAST CANCER, PREVENTIVE MEDICATION
USPSTF Recommendation
The USPSTF recommends that clinicians engage in shared, informed decision making with women who are at increased risk for breast cancer about medications to reduce their risk. For women who are at increased risk for breast cancer and at low risk for adverse medication effects, clinicians should offer to prescribe risk-reducing medications, such as tamoxifen or raloxifene. (Grade B) Examples of screening tools include, but are not limited to Ontario Family Health Assessment tool, Manchester Scoring System, Referral Screening tool or the Pedigree Assessment tool.

 

CPT Codes:

CPT 99401 – 99404

 

ICD-9 Codes:

V16.3

V84.01

 

ICD-10 Codes:

Z803

Z1501

 

BREAST CANCER, SCREENING (MAMMOGRAPHY)

USPSTF Recommendation

The USPSTF currently recommends biennial screening mammography for women with or without clinical breast examination every 1 – 2 years for women 40 years of age and older. (Grade B)

 

CPT/HCPCS Codes:

CPT 77052 (code deleted as of 1/1/2017)

CPT 77057 (code deleted as of 1/1/2017)

CPT 77067 (effective 1/1/2017)

HCPCS G0202

 

ICD-9 Codes:

V76.10 — Breast screening, unspecified

V76.11 — Screening mammogram for high-risk patient

V76.12 — Other screening mammogram

V76.19 — Other screening breast examination

 

ICD-10 Codes:

Z1239

Z1231

 

BREASTFEEDING, COUNSELING

USPSTF Recommendation

The USPSTF recommends interventions during pregnancy and after birth to promote and support breastfeeding. (Grade B)

 

CPT Codes:

CPT 99401

CPT 99402

 

ICD-9 Codes:

V22.0 – V24.2

V24.1 — Postpartum care and examination of lactating mothers

 

ICD-10 Codes:

Z331

Z34 – Z3493

O0900 – O0993

Z390 – Z392

 

NOTE: CAM 046 also addresses breast pumps and indicates the following two breast pumps are allowable for members who qualify for no cost sharing: the Ameda Purely Yours electric pump and the Ameda One Hand Manual pump. 

 

CERVICAL CANCER, SCREENING

USPSTF Recommendation

The USPSTF recommends screening for cervical cancer in women ages 21 to 65 years with cytology (Pap smear) every 3 years OR for women ages 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years. (Grade A)

 

HRSA (Bright Futures) Recommendation

Bright Futures recommends screening for cervical dysplasia with Pap smear within 3 years of onset of sexual activity.

 

CPT/HCPCS Codes:

CPT 87623 – 87625

CPT 88141 – 88153

CPT 88164 – 88167

CPT 88174 – 88175

CPT 0500T

HCPCS G0101

HCPCS G0123 – G0124

HCPCS G0144 – G0145

 

ICD-9 Codes:

V723 — Gynecological exam

V72.31 — Routine gynecological examination

V72.32 — Encounter for Papanicolaou cervical smear to confirm findings of recent normal smear following initial abnormal smear

V73.81 — Special screening examination for Human papillomavirus (HPV)

V76.2 — Special screening for malignant neoplasm of the cervix

 

ICD-10 Codes:

Z01411

Z01419

Z0142

Z124

Z1151

 

CHLAMYDIA INFECTION, SCREENING IN WOMEN & ADOLESCENTS

USPSTF Recommendation

The USPSTF recommends screening for chlamydial infection for all sexually active non-pregnant young women aged 24 and younger and for older non-pregnant women who are at increased risk. (Grade A)

                                                                  AND

The USPSTF recommends screening for chlamydial infection for all pregnant women age 24 and younger and for older pregnant women who are at increased risk. (Grade B)

 

HRSA (Bright Futures) Recommendation

Screen sexually active adolescents for chlamydia using tests appropriate to the patient population and clinical setting.

 

CPT Codes:

CPT 87490

CPT 87491

 

ICD-9 Codes:

V73.88 — Special screening examination for other specified chlamydial diseases

V73.98 — Special screening examination for unspecified chlamydial disease

 

ICD-10 Code:

Z118

 

CONTRACEPTION:

Food and Drug Administration-approved contraceptive methods, sterilization procedures and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”

 

NOTE: The procedure filed will be used to determine no cost share issues, not the diagnosis filed.

NOTE: For 96372 to be considered for no cost share, J1050 will need to be filed on the same date of service

NOTE: Coverage may be governed by state or federal mandates. 

FDA approved mobile application (app) for contraception (e.g., Natural Cycles) is covered per member’s contract.

• Members will have to file manual claim to receive reimbursement for their subscription to Natural Cycles and submit the following:
  • The Natural Cycles annual subscription receipt with the CPT code 99199 and diagnosis code Z30.8 on the receipt
  • A prescription from an in-network provider that includes the name of the mobile application, Natural Cycles
• Effective 1/1/2024, one annual subscription to Natural Cycles will be covered per benefit period. No additional supplies or services are covered

Code A9293 may be used for contraception mobile application

NOTE: For all over the counter or self purchased contraceptives, the member will file the request for reimbursement including the receipt of their payment.

CPT and HCPCS codes associated with contraceptives and sterilization:

00851	Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy.
11976	Removal, implantable contraceptive capsules
11980	Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets beneath the skin)
11981	Insertion, non-biodegradable drug delivery implant (e.g., Implanon)
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)
58340	CATHETERIZATION AND INTRODUCTION OF SALINE OR CONTRAST MATERIAL FOR SALINE INFUSION SONOHYSTEROGRAPHY (SIS) OR HYSTEROSALPINGOGRAPHY
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
58611	Ligation or transection of fallopian tube(s) when done at time of cesarean or intra-abdominal surgery
58615	Occlusion of fallopian tube(s), by device (e.g., band, clip, Falope ring) vaginal or suprapubic approach
58661	Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy). If filed with diagnosis Z30.2
58670	LAPAROSCOPY, SURGICAL; WITH FULGURATION OF OVIDUCTS (WITH OR WITHOUT TRANSECTION). If filed with diagnosis Z30.2.
58671	Laparoscopy, surgical, with occlusion of oviducts by device (e.g., band, clip or Falope ring)
58700	***SALPINGECTOMY, COMPLETE OR PARTIAL, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE)
96372	Therapeutic, Prophylactic or Diagnostic injection (specify substance or drug); subcutaneous or intramuscular
A4261	Cervical cap for contraceptive use
A4264	Permanent implantable contraceptive intratubal occlusion device(s) and delivery system
A4266	DIAPHRAGM FOR CONTRACEPTIVE USE
A4267	Contraceptive supply, condom, male, each to the grid of contraceptives.
A4268	CONTRACEPTIVE SUPPLY, CONDOM, FEMALE, EACH
A4269	CONTRACEPTIVE SUPPLY, SPERMICIDE (E.G., FOAM, GEL), EACH
J1050	Medroxyprogesterone acetate, 1 mg
J7296	Levonorgestrel-releasing intrauterine contraceptive system (Kyleena), 19.5 mg
J7297	Levonorgestrel-releasing intrauterine contraceptive system, 52 mg, 3 year duration
J7298	Levonorgestrel-releasing intrauterine contraceptive system, 52 mg, 5 year duration
J7300	Intrauterine copper contraceptive
J7302 (code deleted 1/1/2016)	Levonorgestrel-releasing intrauterine contraceptive system (e.g., Mirena)
J7303	Contraceptive supply, hormone containing vaginal ring, each
J7304	Contraceptive supply, hormone containing patch, each
J7306	Levonorgestrel (contraceptive) implant system, including implants and supplies
J7307	Etonogestrel (contraceptive) implant system, including implant and supplies
Q9984 (code deleted 1/1/2018)	Kyleena™ (levonorgestrel-releasing intrauterine system) 19.5 mg
S4981	Insertion of levonorgestrel-releasing intrauterine system (e.g., Mirena)
S4989	Contraceptive intrauterine device (e.g., Progestasert IUD)
S4993	CONTRACEPTIVE PILLS FOR BIRTH CONTROL
Diagnosis codes:
V15.7	PERSONAL HISTORY OF CONTRACEPTION, PRESENTING HAZARDS TO HEALTH
V25.01	Prescription of oral contraceptives
V25.02	Initiation of other contraceptive measures.
V25.03	Encounter for emergency contraceptive counseling and prescription.
V25.04	Counseling and instruction in natural family planning to avoid pregnancy
V25.09	Other family planning advice
V25.11	Encounter for insertion of intrauterine contraceptive device
V25.12	Encounter for removal of intrauterine contraceptive device
V25.13	Encounter for removal and reinsertion of intrauterine contraceptive device.
V25.2	Sterilization
V25.40	CONTRACEPTIVE SURVEILLANCE, UNSPECIFIED
V25.41	Contraceptive pill
V25.42	Intrauterine contraceptive device
V25.43	Implantable subdermal contraceptive
V25.49	Other contraceptive method
V25.5	Insertion of implantable subdermal contraceptive
V25.8	OTHER SPECIFIED CONTRACEPTIVE MANAGEMENT
V25.9	UNSPECIFIED CONTRACEPTIVE MANAGEMENT
V26.41	PROCREATIVE COUNSELING AND ADVICE USING NATURAL FAMILY PLANNING
V26.49	OTHER PROCREATIVE MANAGEMENT COUNSELING AND ADVICE
V26.51	TUBAL LIGATION STATUS
V45.51	PRESENCE OF INTRAUTERINE CONTRACEPTIVE DEVICE
V45.52	PRESENCE OF SUBDERMAL CONTRACEPTIVE IMPLANT
V45.59	PRESENCE OF OTHER CONTRACEPTIVE DEVICE
Z30.2	Encounter for sterilization
996.32	Mechanical complication due to intrauterine contraceptive device
ICD-9 procedures:
66.21	BILATERAL ENDOSCOPIC LIGATION AND CRUSHING OF FALLOPIAN TUBES
66.22	BILATERAL ENDOSCOPIC LIGATION AND DIVISION OF FALLOPIAN TUBES
66.29	OTHER BILATERAL ENDOSCOPIC DESTRUCTION OR OCCLUSION OF FALLOPIAN TUBES
66.31	OTHER BILATERAL LIGATION AND CRUSHING OF FALLOPIAN TUBES
66.32	OTHER BILATERAL LIGATION AND DIVISION OF FALLOPIAN TUBES
66.39	OTHER BILATERAL DESTRUCTION OR OCCLUSION OF FALLOPIAN TUBES
66.51	REMOVAL OF BOTH FALLOPIAN TUBES AT SAME OPERATIVE EPISODE
66.52	REMOVAL OF REMAINING FALLOPIAN TUBE
66.92	UNILATERAL DESTRUCTION OR OCCLUSION OF FALLOPIAN TUBE
69.7	INSERTION OF INTRAUTERINE CONTRACEPTIVE DEVICE
97.71	REMOVAL OF INTRAUTERINE CONTRACEPTIVE DEVICE
ICD-10 Codes
Z920	Personal History of contraception
Z30018	Encounter for initial prescription of other contraceptives
Z30012	Encounter for prescription of emergency contraception
Z3009	Encounter for other general counseling and advice on contraception
Z3002	Counseling and instruction in natural family planning to avoid pregnancy
Z30430	Encounter for insertion of intrauterine contraceptive device
Z30432	Encounter for removal of intrauterine contraceptive device
Z302	Encounter for sterilization
Z3041	Encounter for surveillance of contraceptive pills
Z30431	Encounter for routine checking of intrauterine contraceptive device
Z3049	Encounter for surveillance of other contraceptives
Z308	Encounter for other contraceptive management
Z309	Encounter for contraceptive management, unspecified
Z3161	Procreative counseling and advice using natural family planning
Z3169	Encounter for other general counseling and advice on procreation
Z9851	Tubal ligation status
Z975	Presence of (intrauterine) contraceptive device
T8339XA	Other mechanical complication of intrauterine contraceptive device, initial encounter
ICD-10 Procedures
0UPD7HZ	Removal of Contraceptive Device from Uterus and Cervix, Via Natural or Artificial Opening
0UPD8HZ	Removal of Contraceptive Device from Uterus and Cervix, Via Natural or Artificial Opening Endoscopic
0UH97HZ	Insertion of Contraceptive Device into Uterus, Via Natural or Artificial Opening
0UH98HZ	Insertion of Contraceptive Device into Uterus, Via Natural or Artificial Opening Endoscopic
0UHC7HZ	Insertion of Contraceptive Device into Cervix, Via Natural or Artificial Opening
0UHC8HZ	Insertion of Contraceptive Device into Cervix, Via Natural or Artificial Opening Endoscopic
0U550ZZ	Destruction of Right Fallopian Tube, Open Approach
0U553ZZ	Destruction of Right Fallopian Tube, Percutaneous Approach
0U554ZZ	Destruction of Right Fallopian Tube, Percutaneous Endoscopic Approach
0U557ZZ	Destruction of Right Fallopian Tube, Via Natural or Artificial Opening
0U558ZZ	Destruction of Right Fallopian Tube, Via Natural or Artificial Opening Endoscopic
0U560ZZ	Destruction of Left Fallopian Tube, Open Approach
0U563ZZ	Destruction of Left Fallopian Tube, Percutaneous Approach
0U564ZZ	Destruction of Left Fallopian Tube, Percutaneous Endoscopic Approach
0U567ZZ	Destruction of Left Fallopian Tube, Via Natural or Artificial Opening
0U568ZZ	Destruction of Left Fallopian Tube, Via Natural or Artificial Opening Endoscopic
0UL50CZ	Occlusion of Right Fallopian Tube with Extraluminal Device, Open Approach
0UL50DZ	Occlusion of Right Fallopian Tube with Intraluminal Device, Open Approach
0UL50ZZ	Occlusion of Right Fallopian Tube, Open Approach
0UL53CZ	Occlusion of Right Fallopian Tube with Extraluminal Device, Percutaneous Approach
0UL53DZ	Occlusion of Right Fallopian Tube with Intraluminal Device, Percutaneous Approach
0UL53ZZ	Occlusion of Right Fallopian Tube, Percutaneous Approach
0UL54CZ	Occlusion of Right Fallopian Tube with Extraluminal Device, Percutaneous Endoscopic Approach
0UL54DZ	Occlusion of Right Fallopian Tube with Intraluminal Device, Percutaneous Endoscopic Approach
0UL54ZZ	Occlusion of Right Fallopian Tube, Percutaneous Endoscopic Approach
0UL57DZ	Occlusion of Right Fallopian Tube with Intraluminal Device, Via Natural or Artificial Opening
0UL57ZZ	Occlusion of Right Fallopian Tube, Via Natural or Artificial Opening
0UL58DZ	Occlusion of Right Fallopian Tube with Intraluminal Device, Via Natural or Artificial Opening Endoscopic
0UL58ZZ	Occlusion of Right Fallopian Tube, Via Natural or Artificial Opening Endoscopic
0UL60CZ	Occlusion of Left Fallopian Tube with Extraluminal Device, Open Approach
0UL60DZ	Occlusion of Left Fallopian Tube with Intraluminal Device, Open Approach
0UL60ZZ	Occlusion of Left Fallopian Tube, Open Approach
0UL63CZ	Occlusion of Left Fallopian Tube with Extraluminal Device, Percutaneous Approach
0UL63DZ	Occlusion of Left Fallopian Tube with Intraluminal Device, Percutaneous Approach
0UL63ZZ	Occlusion of Left Fallopian Tube, Percutaneous Approach
0UL64CZ	Occlusion of Left Fallopian Tube with Extraluminal Device, Percutaneous Endoscopic Approach
0UL64DZ	Occlusion of Left Fallopian Tube with Intraluminal Device, Percutaneous Endoscopic Approach
0UL64ZZ	Occlusion of Left Fallopian Tube, Percutaneous Endoscopic Approach
0UL67DZ	Occlusion of Left Fallopian Tube with Intraluminal Device, Via Natural or Artificial Opening
0UL67ZZ	Occlusion of Left Fallopian Tube, Via Natural or Artificial Opening
0UL68DZ	Occlusion of Left Fallopian Tube with Intraluminal Device, Via Natural or Artificial Opening Endoscopic
0UL68ZZ	Occlusion of Left Fallopian Tube, Via Natural or Artificial Opening Endoscopic
0UT50ZZ	Resection of Right Fallopian Tube, Open Approach
0UT54ZZ	Resection of Right Fallopian Tube, Percutaneous Endoscopic Approach
0UT57ZZ	Resection of Right Fallopian Tube, Via Natural or Artificial Opening
0UT58ZZ	Resection of Right Fallopian Tube, Via Natural or Artificial Opening Endoscopic
0UT5FZZ	Resection of Right Fallopian Tube, Via Natural or Artificial Opening With Percutaneous Endoscopic Assistance
0UT60ZZ	Resection of Left Fallopian Tube, Open Approach
0UT64ZZ	Resection of Left Fallopian Tube, Percutaneous Endoscopic Approach
0UT67ZZ	Resection of Left Fallopian Tube, Via Natural or Artificial Opening
0UT68ZZ	Resection of Left Fallopian Tube, Via Natural or Artificial Opening Endoscopic
0UT6FZZ	Resection of Left Fallopian Tube, Via Natural or Artificial Opening With Percutaneous Endoscopic Assistance
0UT70ZZ	Resection of Bilateral Fallopian Tubes, Open Approach
0UT74ZZ	Resection of Bilateral Fallopian Tubes, Percutaneous Endoscopic Approach
0UT77ZZ	Resection of Bilateral Fallopian Tubes, Via Natural or Artificial Opening
0UT78ZZ	Resection of Bilateral Fallopian Tubes, Via Natural or Artificial Opening Endoscopic
0UT7FZZ	Resection of Bilateral Fallopian Tubes, Via Natural or Artificial Opening With Percutaneous Endoscopic Assistance
0U570ZZ	Destruction of Bilateral Fallopian Tubes, Open Approach
0U573ZZ	Destruction of Bilateral Fallopian Tubes, Percutaneous Approach
0U577ZZ	Destruction of Bilateral Fallopian Tubes, Via Natural or Artificial Opening
0UL70CZ	Occlusion of Bilateral Fallopian Tubes with Extraluminal Device, Open Approach
0UL70DZ	Occlusion of Bilateral Fallopian Tubes with Intraluminal Device, Open Approach
0UL70ZZ	Occlusion of Bilateral Fallopian Tubes, Open Approach
0UL73CZ	Occlusion of Bilateral Fallopian Tubes with Extraluminal Device, Percutaneous Approach
0UL73DZ	Occlusion of Bilateral Fallopian Tubes with Intraluminal Device, Percutaneous Approach
0UL73ZZ	Occlusion of Bilateral Fallopian Tubes, Percutaneous Approach
0UL77DZ	Occlusion of Bilateral Fallopian Tubes with Intraluminal Device, Via Natural or Artificial Opening
0UL77ZZ	Occlusion of Bilateral Fallopian Tubes, Via Natural or Artificial Opening
0UL70ZZ	Occlusion of Bilateral Fallopian Tubes, Open Approach
0UL73ZZ	Occlusion of Bilateral Fallopian Tubes, Percutaneous Approach
0UL77ZZ	Occlusion of Bilateral Fallopian Tubes, Via Natural or Artificial Opening
0U574ZZ	Destruction of Bilateral Fallopian Tubes, Percutaneous Endoscopic Approach
0U578ZZ	Destruction of Bilateral Fallopian Tubes, Via Natural or Artificial Opening Endoscopic
0UL74CZ	Occlusion of Bilateral Fallopian Tubes with Extraluminal Device, Percutaneous Endoscopic Approach
0UL74DZ	Occlusion of Bilateral Fallopian Tubes with Intraluminal Device, Percutaneous Endoscopic Approach
0UL74ZZ	Occlusion of Bilateral Fallopian Tubes, Percutaneous Endoscopic Approach
0UL78DZ	Destruction of Bilateral Fallopian Tubes, Percutaneous Endoscopic Approach
0UL78ZZ	Destruction of Bilateral Fallopian Tubes, Via Natural or Artificial Opening Endoscopic
0UL74CZ	Occlusion of Bilateral Fallopian Tubes with Extraluminal Device, Percutaneous Endoscopic Approach
0UL74DZ	Occlusion of Bilateral Fallopian Tubes with Intraluminal Device, Percutaneous Endoscopic Approach
0UL74ZZ	Occlusion of Bilateral Fallopian Tubes, Percutaneous Endoscopic Approach
0UL78DZ	Occlusion of Bilateral Fallopian Tubes with Intraluminal Device, Via Natural or Artificial Opening Endoscopic
0UL78ZZ	Occlusion of Bilateral Fallopian Tubes, Via Natural or Artificial Opening Endoscopic
0UL74ZZ	Occlusion of Bilateral Fallopian Tubes, Percutaneous Endoscopic Approach
0UL78ZZ	Occlusion of Bilateral Fallopian Tubes, Via Natural or Artificial Opening Endoscopic

 

DIABETES MELLITUS, SCREENING IN PREGNANT WOMEN 24 – 28 WEEKS GESTATION AND AT FIRST PRENATAL VISIT FOR PREGNANT WOMEN IDENTIFIED AS HIGH RISK FOR DIABETES

USPSTF Recommendation

The USPSTF recommends screening for gestational diabetes mellitus in asymptomatic pregnant women after 24 weeks of gestation. (Grade B)

 

CPT Codes:

CPT 82947

CPT 82948

CPT 82950

 

ICD-9 Codes:

V22.0 – V22.2

V23.0 – V23.9

V77.1 — Screening for diabetes mellitus

 

ICD-10 Codes:

Z131

Z331

Z34 – Z3493

O0900 – O093

 

FOLIC ACID, PREVENTION OF NEURAL TUBE DEFECTS

USPSTF Recommendation

The USPSTF recommends that all women planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 to 800 µg) (Grade A) of folic acid. Not routinely covered for “all women capable of pregnancy.” (Grade A)

Effective August 2023:

The USPSTF recommends that all persons planning to or who could become pregnant take a daily supplement containing 0.4 – 0.8 mg (400 – 800mcg) of folic acid.

 

CPT/HCPCS Code:

A9152  

 

GONORRHEA, SCREENING

USPSTF Recommendation

The USPSTF recommends that clinicians screen all sexually active women, including those who are pregnant, for gonorrhea infection if they are at increased risk for infection (i.e., if young or have other individual or population. (Grade B)

 

HRSA (Bright Futures) Recommendation

Screen sexually active adolescents for gonorrhea using tests appropriate to the patient population and clinical setting.

 

CPT Codes:

CPT 87590

CPT 87591

CPT 87850

 

ICD-9 Codes:

V70.0

V72.3

V72.31

V74.5

V22.0 – V24.2

 

ICD-10 Codes:

Z0000

Z01411

Z01419

Z113

Z331

Z34 – Z3493

O0900 – O0933

Z390 – Z392

 

HEPATITIS B VIRUS INFECTION IN PREGNANCY, SCREENING

USPSTF Recommendation

The USPSTF strongly recommends screening for hepatitis B virus infection in pregnant women at their first prenatal visit (Grade A).

 

CPT Codes:

CPT 80055

CPT 80081

CPT 87340

 

ICD-9 Codes:

V22.0 – V22.2 — Prenatal visits

V23.0 – V23.9 — Prenatal visits for patients with high risk pregnancies

V28.9 — Antenatal screening NOS

 

ICD-10 Codes:

Z34 – Z3493

O0900 – O0993

Z36

 

HUMAN IMMUNODEFICIENCY VIRUS (HIV), COUNSELING AND SCREENING

USPSTF Recommendation

The USPSTF recommends that clinicians screen for human immunodeficiency virus (HIV) in adolescents and adults ages 15 – 65 years. Younger adolescents and older adults who are at increased risk should also be screened. (Grade A)

The USPSTF recommends that clinicians screen all pregnant women for HIV, including those who present in labor who are untested and whose HIV status is unknown. (Grade A)

HRSA (Bright Futures) Recommendation

Sexually active adolescents who are positive on risk questions should be screened for HIV.

 

CPT/HCPCS Codes:

CPT 86703

CPT 87389

CPT 87390

CPT 99401

CPT 99402

HCPCS G0432

HCPCS G0433

HCPCS G0435

HCPCS S3645

 

ICD-9 Codes:

V01.79

V22.0 – V24.2

 

ICD-10 Codes:

Z206

Z20828

Z331

Z34 – Z3493

O0900 – O0933 

  

INTIMATE PARTNER VIOLENCE, SCREENING/COUNSELING OF WOMEN, ANNUALLY

USPSTF Recommendation

The USPSTF recommends that clinicians screen women of childbearing age for intimate partner violence, such as domestic violence, and provide or refer women who screen positive to intervention services. This recommendation applies to women who do not have signs or symptoms of abuse.

 

CPT/HCPCS Codes:

CPT 99401 *CPT 99402 – CPT 99404 require review of records.

 

ICD-9 Code:

V61.11 — Counseling for victim of spousal and partner abuse

 

ICD-10 Code:

Z6911

 

IRON DEFICIENCY ANEMIA SCREENING IN PREGNANT WOMEN

USPSTF Recommendation

The USPSTF recommends routine screening for iron deficiency anemia in asymptomatic pregnant women. (Grade B).

 

CPT Codes:

CPT 80055

CPT 80081

CPT 85013

CPT 85014

CPT 85018

 

ICD-9 Codes:

V22.0 – V23.9

 

ICD-10 Codes:

Z331

Z34 – Z3493

O0900 – O0933 

   

OSTEOPOROSIS SCREENING IN WOMEN

USPSTF Recommendation

The USPSTF recommends screening for osteoporosis in women age 65 and older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors. (Grade B).

 

Verbiage updated in June 2018 does not impact coding:

 

The USPSTF recommends screening for osteoporosis to prevent osteoporotic fractures in postmenopausal women younger than 65 years who are at increased risk for an osteoporotic fracture, as determined by a formal clinical risk assessment tool.

 

The USPSTF recommends screening for osteoporosis to prevent osteoporotic fractures in women 65 years and older.

 

CPT Code:

CPT 77080

 

ICD-9 Code:

V82.81 Special screening for osteoporosis

 

ICD-10 Code:

Z13820

 

PRE-ECLAMPSIA PREVENTION: ASPIRIN

USPSTF Recommendations:

The USPSTF recommends the use of low-dose aspirin (81 mg/d) as preventive medication after 12 weeks of gestation in women who are at high risk for pre-eclampsia.

  

PRE-ECLAMPSIA SCREENING: BLOOD PRESSURE

 

April 2017 B recommendation:

 

The USPSTF recommends screening for pre-eclampsia in pregnant women with blood pressure measurements throughout pregnancy.

   

RH INCOMPATABILITY SCREENING

USPSTF Recommendations

The USPSTF strongly recommends Rh (D) blood typing and antibody testing for all pregnant women during their first visit for pregnancy-related care. (Grade A)

The USPSTF recommends repeated Rh (D) antibody testing for all unsensitized Rh (D)-negative women at 24 – 28 weeks' gestation, unless the biological father is known to be Rh (D)-negative. (Grade B)

 

CPT Codes:

CPT 80055

CPT 80081

CPT 86901

 

ICD-9 Codes:

V22.0 – V23.9 

 

ICD-10 Codes: 

Z331

Z34 – Z3493

O0900 – O0933

 

SCREENING FOR DIABETES MELLITUS AFTER PREGNANCY

HRSA recommends women with a history of gestational diabetes mellitus who are not currently pregnant and who have not previously been diagnosed with Type 2 diabetes mellitus should be screened for diabetes mellitus. Initial screening should ideally occur within the first year postpartum and can be conducted as early as 4 – 6 weeks postpartum. Women with a negative initial postpartum screening test result should be rescreened at least every 3 years for a minimum of 10 years after pregnancy.

 

CPT CODE

82951

 

ICD-9 CODE

V12.21

 

ICD-10 CODE

Z86.32

 

SCREENING FOR URINARY INCONTINENCE

HRSA recommends screening women for urinary incontinence annually.

 

CPT CODES

99401

1090f

 

SEXUALLY TRANSMITTED INFECTIONS (STIs); BEHAVIORAL COUNSELING TO PREVENT

USPSTF Recommendation

The USPSTF recommends high intensity behavioral counseling to prevent sexually transmitted infections (STIs) for all sexually active adolescents and for adults at increased risk for STIs. (Grade B)

 

CPT Codes:

CPT 99401

CPT 99402

 

ICD-9 Codes:

V65.44 — Human immunodeficiency virus counseling

V65.45 — Counseling on other sexually transmitted diseases

V69.2 — Problems related to high-risk sexual behavior

 

ICD-10 Codes:

Z717

Z7189

Z7251 – Z7253

   

SYPHILIS, SCREENING

USPSTF Recommendation

The USPSTF recommends that clinicians screen all persons at increased risk for syphilis infection, and all pregnant women for syphilis infection. (Grade A)

 

HRSA (Bright Futures) Recommendation

Bright Futures recommends screening for syphilis in all adolescents who are sexually active and positive for high risk.

 

CPT Codes:

CPT 80055

CPT 80081

CPT 86592

CPT 86780

 

ICD-9 Codes:

V22.0 – V23.9

V69.2

V74.5 

 

ICD-10 Codes:

Z331

Z34 – Z3493

O0900 – O0993

Z7251

Z113

Z7251 – Z7253

 

TOBACCO USE, SCREENING, COUNSELING AND INTERVENTIONS

USPSTF Recommendation

The USPSTF recommends that clinicians ask all adults about tobacco use, advise them to stop using tobacco and provide behavioral interventions and U.S. Food and Drug Administration (FDA)-approved pharmacotherapy for cessation to adults who use tobacco.

(Grade A)

 

The USPSTF recommends that clinicians ask all pregnant women about tobacco use, advise them to stop using tobacco and provide behavioral interventions for cessation to pregnant women who use tobacco.

(Grade A)

 

The USPSTF recommends that clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use in school-aged children.

 

CPT Codes:

CPT 99406

CPT 99407

 

ICD-9 Codes:

305.1 — Tobacco dependence

649.01 – 649.04 — Smoking complicating pregnancy

V15.82 — History of tobacco use

V15.89 — Other specified personal history presenting hazards to health, Other

 

ICD-10 Codes:

F17200

O99331 – O9335

Z87891

Z779

Z9289

 

Well-woman preventive care visit is recommended annually to obtain the recommended preventive services that are age and developmentally appropriate.

 

NOTE: The procedure filed will be used to determine no cost share issues, not the diagnosis filed.

Gynecological:

S0610      ANNUAL GYNECOLOGICAL EXAMINATION, NEW PATIENT

S0612      ANNUAL GYNECOLOGICAL EXAMINATION, ESTABLISHED PATIENT

S0613      ANNUAL GYNECOLOGICAL EXAMINATION; CLINICAL BREAST EXAMINATION WITHOUT PELVIC EVALUATION

New Patient:

99384      (Age 12 – 17) INITIAL COMPREHENSIVE PREVENTIVE MEDICINE EVALUATION AND MANAGEMENT

99385      (Age 18 – 39) INITIAL COMPREHENSIVE PREVENTIVE MEDICINE EVALUATION AND MANAGEMENT

99386      (Age 40 – 64) INITIAL COMPREHENSIVE PREVENTIVE MEDICINE EVALUATION AND MANAGEMENT

99387      (Age 65 year and older) INITIAL COMPREHENSIVE PREVENTIVE MEDICINE EVALUATION AND MANAGEMENT

Established Patient:

99394      (Age 12 – 17) PERIODIC COMPREHENSIVE PREVENTIVE MEDICINE REEVALUATION AND MANAGEMENT

99395      (Age 18 – 39) PERIODIC COMPREHENSIVE PREVENTIVE MEDICINE REEVALUATION AND MANAGEMENT

99396      (Age 40 – 64) PERIODIC COMPREHENSIVE PREVENTIVE MEDICINE REEVALUATION AND MANAGEMENT

99397      (Age 65 years and older) PERIODIC COMPREHENSIVE PREVENTIVE MEDICINE REEVALUATION AND MANAGEMENT

Annual Wellness Visit:

G0438      ANNUAL WELLNESS VISIT; INCLUDES A PERSONALIZED PREVENTION PLAN

G0439      ANNUAL WELLNESS VISIT, INCLUDES A PERSONALIZED PREVENTION PLAN

S5190      WELLNESS ASSESSMENT, PERFORMED BY NON-PHYSICIAN

99459 is an add on code effective 01012024 to reflect the work of a pelvic examination and should be filed in addition to the primary procedure.

ICD-9 Codes:

V72.3 Gynecological examination

V72.31 Routine gynecological examination 

ICD-10 Code:

Z01419

Reference 

1. Internet Citation: USPSTF A and B Recommendations, U.S. Preventive Services Task Force. October 2014  http://www.uspreventiveservicestaskforce.org/Page/Name/upstf-a-and-b-recommendations/ 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community,  and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved"