Women's Preventive Services - CAM 094HB
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
- 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.
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