Description
The U.S. Patient Protection and Affordable 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 and B recommendations are covered without cost sharing (i.e., deductible, coinsurance, or copay) 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 copay 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.
Please note that the coding represented in the policy does not take into consideration bundling and editing rules that may apply to them.
Policy:
ABDOMINAL AORTIC ANEURYSM, SCREENING
USPSTF Recommendation
The USPSTF recommends one-time screening for abdominal aortic aneurysm (AAA) screening for men ages 65 – 75 who have ever smoked. (Grade B)
CPT/HCPCS Codes
G0389 — Ultrasound b-scan and/or real time with image documentation; for abdominal aortic aneurysm (aaa) screening
76706 (effective 1/1/2017) — Ultrasound, abdominal sorta, real time with image documentation, screening study for abdominal aortic aneurysm (AAA)
ICD-9 Codes
V15.82 — Personal history of tobacco use, presenting hazards to health
V81.2 — Other and unspecified cardiovascular conditions
ICD-10 Codes
Z87891
Z136
ALCOHOL AND DRUG USE SCREENING FOR ADOLESCENTS BEGINNING AT AGE 11 – 18
HRSA (Bright Futures) Recommendation
Bright Futures recommends initiating questioning regarding alcohol or drug use and, if positive, to follow with an alcohol or drug screening tool.
CPT/HCPCS Code
CPT 99408
ANEMIA, SCREENING IN INFANTS, CHILDREN & ADOLESCENTS
HRSA (Bright Futures) Recommendations
Hemoglobin and hematocrit should be screened for at the 4-month well-child visit in children who are preterm or who are low birth weight infants, and those not on iron-fortified formula.
Hemoglobin and hematocrit should be screened for routinely at the 12-month well-child visit.
Hemoglobin and hematocrit should be screened selectively for children who are positive for risk screening questions at the 15 month – 21 year visits.
CPT/HCPCS Codes
CPT 85014
CPT 85018
ANXIETY DISORDERS IN ADULTS: SCREENING ADULTS 64 YEARS OR YOUNGER,INCLUDING PREGNANT AND POSTPARTUMPERSONS:
The USPSTF recommends screening for anxiety disorders in adults , including pregnant and postpartum persons.
CPT/HCPCS codes
CPT 99420 administration and interpretation of health risk assessment instrument
CPT 96160 administration of patient focused health risk assessment instrument
CPT 96161 administration of caregiver focused health risk assessment instrument
HCPCS G0444
ICD 9 V79.0
ICD10 Z1331
ASPIRIN TO PREVENT CARDIOVASCULAR DISEASE IN ADULTS
EFFECTIVE JULY 1, 2024, THIS BENEFIT WILL TERMINATE AS THE USPSTF HAS DECREASED THIS RECOMMENDATION TO A C/D RECOMMENDATION.
USPSTF Recommendations
The USPSTF recommends the use of aspirin for men age 45 to 79 years when the potential benefit due to a reduction in myocardial infarctions outweighs the potential harm due to an increase in gastrointestinal hemorrhage. (Grade A)
The USPSTF recommends the use of aspirin for women age 55 to 79 years when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage. (Grade A)
USPSTF recommendation updated April 2016:
The USPSTF recommends initiating low-dose aspirin use for the primary prevention of cardiovascular disease and colorectal cancer in adults aged 50 to 59 years who have a 10% or greater 10-year cardiovascular risk, are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years.
Aspirin Use to Prevent Preeclampsia and Related Morbidity and Mortality: Preventive medication: pregnant persons at high risk for preeclampsia:
The USPSTF recommends the use of low-dose aspirin (81 mg/day) as a preventive medication after 12 weeks of gestation in persons who are at high risk for preeclampsia.
Asymptomatic pregnant persons:
The USPSTF recommends screening for hypertensive disorders of pregnancy with blood pressure measurements throughout pregnancy.
ICD 9 V81.1
ICD 10 Z136
AUTISM, SCREENING
HRSA (Bright Futures) Recommendation
Provide the autism specific screening test at the 18-month and 24-month well-child visits.
CPT/HCPCS Codes
CPT 96110
HCPCS G0451
Anxiety in Children and Adolescents: Screening: Children and adolescents aged 8 – 18 years
The USPSTF recommends screening for anxiety in children and adolescents 8 – 18 years
CPT/HCPCS codes
CPT 99420-administration and interpretation of health risk assessment instrument
CPT 96160 administration of patient-focused health risk assessment instrument
CPT 96161 administration of caregiver-focused health risk assessment instrument
CPT 96127 brief emotional/behavioral assessment with scoring and documentation per standardized instrument
HCPCS G0444
ICD9 V79.0
ICD10 Z1331
BACTERIURIA, SCREENING IN PREGNANT WOMEN
USPSTF Recommendation
The USPSTF recommends screening for asymptomatic bacteriuria using urine culture in pregnant persons. (Grade B)
CPT/HCPCS 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
Z34 – Z3493
Z331
O0900 – O0993
BRCA TESTING, RISK ASSESSMENT GENETIC COUNSELING/TESTING
USPSTF RECOMMENDATION
The USPSTF recommends that primary care clinicians assess women with a personal or family history of breast, ovarian, tubal, or peritoneal cancer or who have an ancestry associated with breast cancer susceptibility 1 and 2 gene mutations with an appropriate brief familial risk assessment tool. Women with a positive result on the risk assessment tool should receive genetic counseling and, if indicated after counseling, genetic testing. (grade B)
CPT/HCPCS Codes:
CPT 99385 – 99387
CPT 99395 – 99397
CPT 8211 (Code deleted effective 01/01/2019)
CPT 81212 – 81217 (code effective 01/01/2019)
CPT 81162
CPT 81163 – 81167
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 offer to prescribe risk-reducing medications, such as tamoxifen, raloxifene, or aromatase inhibitors, to women who are at increased risk for breast cancer and at low risk for adverse medication effects. (Grade B)
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 aged 40 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) — Screening mammography, bilateral (2-view study of each breast), including computer-aided detection )CAD) when performed
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/HCPCS Codes
CPT 99401
CPT 99402
ICD-9 Codes
V22.0 – V24.2
V24.1 — Postpartum care and examination of lactating mothers.
ICD-10 Codes
Z34 – Z3493
Z331
Z390 – Z392
O0900 – O0993
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 every 3 years with cervical cytology alone in women aged 21 to 29 years. For women aged 30 to 65 years, the USPSTF recommends screening every 3 years with cervical cytology alone, every 5 years with high-risk human papillomavirus (hrHPV) testing alone, or every 5 years with hrHPV testing in combination with cytology (cotesting).
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)
Effective September 2021. The USPSTF recommends screening for chlamydia in all sexually active women, including pregnant persons, 24 years or younger and in women 25 years or older who are at increased risk for infection.
HRSA (Bright Futures) Recommendation
Screen sexually active adolescents for chlamydia using tests appropriate to the patient population and clinical setting.
CPT/HCPCS 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
V016 — Contact with or exposure to venereal diseases
ICD-10 Code
Z118
Z202
Z7251
Z7252
Z7253
COLORECTAL CANCER, SCREENING
USPSTF Recommendation
Effective May 31, 2022, the USPSTF recommendation has been expanded to include coverage of a follow up colonoscopy without cost share after a positive non-invasive stool- based test or direct visualization.
The USPSTF recommends screening for colorectal cancer starting at age 50 years and continuing until age 75 years. (Recommendation changed effective 05/18/2021.)
Effective May 18, 2021:
The USPSTF recommends screening for colorectal cancer for all adults age 45 and continuing until age 75 years.
CPT/HCPCS Codes:
Use of the 33 modifier with specific surgical codes will help identify the procedure as preventive; policy for.
CPT 00810
CPT 00812 (Report 00812 to describe anesthesia for any screening colonoscopy regardless of ultimate findings)
CPT 45330 – 45349
CPT 45378 – 45392
CPT 81528
CPT 82270
CPT 82274
HCPCS G0104
HCPCS G0105
HCPCS G0106
HCPCS G0120
HCPCS G0121
HCPCS G0122
HCPCS G0328
HCPCS effective May 1, 2016, S0285 — Colonoscopy consultation performed prior to a screening colonoscopy procedure
ICD-9 Codes
V76.41 — Screening for malignant neoplasm of the rectum
V76.51 — Special screening for malignant neoplasms, Colon
ICD-10 Codes
Z1212
Z1211
CONGENITAL/INHERITED METABOLIC DISORDERS & HEMOGLOBINOPATHIES
HRSA (Bright Futures) Recommendation
These tests are usually done prior to discharge from the hospital following birth of the infant), but may be allowed up to 30 days of age.
CPT/HCPCS Code
S3620
DENTAL CARIES IN PRESCHOOL CHILDREN
USPSTF Recommendation
The USPSTF recommends the application of fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption in primary care practices. The USPSTF recommends primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is fluoride deficient. (Grade B)
HRSA (Bright Futures) Recommendation
Oral fluoride supplementation from ages 1 – 6 if the primary water source is deficient in fluoride.
CPT HCPCS Codes
99188
D1208
DEPRESSION, SCREENING IN ADULTS
USPSTF Recommendation
The USPSTF recommends screening adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up. (Grade B)
Updated verbiage June 2023:
DEPRESSION AND SUICIDE RISK IN ADULTS: SCREENING ADULTS, INCLUDING PREGNANT AND POSTPARTUM PERSON, AND OLDER ADULTS (65 YEARS OR OLDER)
The USPSTF recommends screening for depression in the adult population, including pregnant and post partum persons, as well as older adults.
CPT/HCPCS Codes
CPT 99420 — Administration and Interpretation of health risk assessment instrument (e.g., health hazard appraisal)
CPT 96160 (effective Jan. 1, 2017) — Administration of patient-focused health risk assessment instrument (e.g., health hazard appraisal) with scoring and documentation, per standardized instrument
CPT 96161 (effective Jan. 1, 2017) — Administration of caregiver-focused health risk assessment instrument (e.g., depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument
CPT 96127 — Brief emotional/behavioral assessment (e.g., depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument.
HCPCS: G0444
ICD-9 Code
V79.0 Screening for depression
ICD-10 Code
Z1331
DEPRESSION, SCREENING IN ADOLESCENTS
USPSTF Recommendation
The USPSTF recommends screening of adolescents (12 –18 years of age) for major depressive disorder (MDD) when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal), and follow-up. (Grade B)
Updated recommendation October 2022: Depression and Suicide Risk in children and Adolescents: Screening adolescents aged 12 – 18 years:
The USPSTF recommends screening for major depressive disorder (MDD) in adolescents aged 12 – 18.
CPT /HCPCS Codes
CPT 99420 — Administration and Interpretation of health risk assessment instrument (e.g., health hazard appraisal)
CPT 96160 (effective Jan. 1, 2017) — Administration of patient-focused health risk assessment instrument (e.g., health hazard appraisal) with scoring and documentation, per standardized instrument
CPT 96161 (effective Jan. 1, 2017) — Administration of caregiver-focused health risk assessment instrument (e.g., depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument
CPT 96127 — Brief emotional/behavioral assessment (e.g., depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument.
HCPCS: G0444
ICD-9 Code
V79.0 Screening for depression
ICD-10 Code
Z1331
DEVELOPMENTAL SCREENING
HRSA (Bright Futures) Recommendation
Begin structured developmental screening at the 9-month well-child visit with repeat evaluation at the 18-month and the 2½-year well-child visits.
CPT/HCPCS Codes
CPT: 96110
(This code is recommended by the AAP [Coding for Pediatric Preventive Care, 2011].)
HCPCS: G0451
DIABETES MELLITUS, TYPE 2, SCREENING IN ADULTS
USPSTF Recommendation
The USPSTF recommends screening for Type 2 Diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg. (Grade B)
Diabetes Screening verbiage was updated in October 2015 to state the following:
The USPSTF recommends screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged 40 to 70 years who are overweight or obese. Clinicians should offer or refer patients with abnormal blood glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity. (grade B)
Diabetes Screening verbiage was updated in August 2021 to state the following:
Screening for Prediabetes and Type 2 Diabetes: asymptomatic adults aged 35 – 70 years who have overweight or obesity:
The USPSTF recommends screening for prediabetes and Type 2 diabetes in adults aged 35 – 70 years who have overweight or obesity. Clinicians should offer to refer patients with prediabetes to effective preventive interventions.
CPT/HCPCS Codes
CPT 82947
CPT 82948
ICD-9 Code
V77.1 — Screening for diabetes mellitus
ICD-10 Code
Z131
R7303
DIABETES MELLITUS, SCREENING IN PREGNANT WOMEN 24 – 28 WEEKS GESTATION AND AT FIRST PRENATAL VISIT FOR PREGNANT WOMEN IDENTIFIED AS HIGH RISK FOR DIABETES
Gestational Diabetes screening was changed in August of 2021 to state:
Gestational Diabetes: Screening: asymptomatic pregnant persons at 24 weeks of gestation or after:
The USPSTF recommends screening for gestational diabetes in asymptomatic pregnant persons at 24 weeks of gestation or after.
USPSTF Recommendation
The USPSTF recommends screening for gestational diabetes mellitus in asymptomatic pregnant women after 24 weeks of gestation. (Grade B)
CPT/HCPCS Codes
CPT 82947
CPT 82948
ICD-9 Code:
V77.1 — Screening for diabetes mellitus
ICD-10 Code
Z131
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/HCPCS 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
Z34 – Z3493
Z331
O0900 – O0993
Z131
FALLS, PREVENTION IN COMMUNITY-DWELLING OLDER ADULTS
USPSTF Recommendation
The USPSTF recommends exercise interventions to prevent falls in community-dwelling adults 65 years or older who are at increased risk for falls.
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)
Updated verbiage August 2023:
The USPSTF recommends that all persons planning to or who could become pregnant take a daily supplement containing 0.4-0.8 (400-800 mcg) of folic acid.
CPT/HCPCS Code
A9152
GONORRHEA, PROPHYLACTIC MEDICATION: NEWBORNS
USPSTF Recommendation
The USPSTF recommends prophylactic ocular topical medication for all newborns to prevent gonococcal ophthalmia neonatorum (Grade A).
ICD-9 Code:
V20.2
ICD-10 Codes
Z00129
Z298 code terms 10/01/2023 and is replaced by Z2989
CPT code: J3490
Of note, this will typically be included in the newborn hospital claim.
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. (Grade B)
Effective September 2021:
The USPSTF recommends screening for gonorrhea in all sexually active women, including pregnant persons, 24 years or younger and in women 25 years or older who are at increased risk for infection.
HRSA (Bright Futures) Recommendation
Screen sexually active adolescents for gonorrhea using tests appropriate to the patient population and clinical setting.
CPT/HCPCS Codes
CPT 87590
CPT 87591
CPT 87850
ICD-9 Codes
V016
V70.0
V72.3
V72.31
V74.5
V22.0 – V24.2
ICD-10 Codes
Z0000
Z01411
Z01419
Z113
Z202
Z34 – Z3493
Z331
Z390 – Z392
Z7251 – Z7253
O0900 – O0993
Healthy Weight and Weight Gain in Pregnancy: Behavioral Counseling Interventions: pregnant persons:
The USPSTF recommends that clinical offer pregnant persons effective behavioral counseling interventions aimed at promoting healthy weight gain and preventing excess gestational weight gain in pregnancy:
CPT
99401 – 99404
99411 – 99412
G0473
G0477
ICD 9:
V220 – V239
64200 – 65161
ICD 10:
All coding starting with O
HEARING LOSS, SCREENING IN NEWBORNS USPSTF Recommendation
The USPSTF recommends screening for hearing loss in all newborn infants (less than one month of age). (Grade B)
After the 4th month, if there are positive responses to risk screening questions, the infant should be referred for diagnostic audiologic assessment.
HRSA (Bright Futures) Recommendation
If not done at birth (e.g., newborn delivered at home or discharged from Neonatal Intensive Care Unit) screening should be completed within the first month of life.
After the 4th month, if there are positive responses to risk screening questions, the infant should be referred for diagnostic audiologic assessment.
At years 4, 5, 6, 8 and 10, audiometry is recommended.
Audtiometry screening with 6,000 and 8,000 Hz high frequency is recommended once between 11 through 14 years of age, once between 15 through 17 years of age and once between 18 through 21 years of age.
CPT/HCPCS Codes
CPT 92551
CPT 92552
CPT 92558
CPT 92586
CPT 92652
CPT 92653
ICD-9 Codes
V30 – V39
ICD-10 Codes
Z380 – Z388
HEPATITIS B SCREENING: nonpregnant adolescents and adults:
The USPSTF recommends screening for hepatitis B virus infection in persons at high risk for infection.
CPT /HCPCS Codes
CPT 80055
CPT 80081
CPT 87340
CDC guidance for high risk for infection includes:
- Persons born in geographic regions with HBsAg prevalence of > 2%.
- U.S.-born persons not vaccinated as infants whose parents were born in geographic regions with HBsAg prevalence of > 8%.
- Injection-drug users.
- Men who have sex with men.
- Persons with elevated ALT/AST of unknown etiology.
- Persons with selected medical conditions who require immunosuppressive therapy.
- Pregnant women.
- Infants born to HBsAg-positive mothers.
- Household contacts and sex partners of HBV-infected persons.
- Persons who are the source of blood or body fluid exposures that might warrant post-exposure prophylaxis (e.g., needle stick injury to a health care worker).
- Persons infected with HIV.
ICD 10:
Z7251 – Z7253
F11 – F169
F18 – F199
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/HCPCS 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
HEPATITIS C VIRUS INFECTIONS SCREENING IN ADULTS
USPSTF Recommendation
The USPSTF recommends screening for hepatitis C virus (HCV) infection in persons at high risk for infection. The USPSTF also recommends offering one-time screening for HCV infection to adults born between 1945 and 1965. (Grade B)
Verbiage for hepatitis C screening updated by the USPSTF March 2020:
The USPSTF recommends screening for hepatitis C virus (HCV) infection in adults ages 18 to 79 years.
CPT/HCPCS Codes
CPT 86803 – 86804
HCPCS G0472
ICD 10
Z7251 – Z7253
F11 – F169
F18 – F199
HIGH BLOOD PRESSURE, SCREENING IN ADULTS (This recommendation was replaced in 04/2021 by the Hypertension in adults Screening recommendation. Please see that recommendation for dates of service after April 2021.)
USPSTF Recommendation
The USPSTF recommends screening for high blood pressure in adults aged 18 and older. (Grade A)
This recommendation was restated in October 2015 to state:
The USPSTF recommends screening for high blood pressure in adults aged 18 years or older. The USPSTF recommends obtaining measurements outside of the clinical setting for diagnostic confirmation before starting treatment. (Grade A)
CPT/HCPCS Codes
CPT 99385 – 99387
CPT 99395 – 99397
CPT 93784 – 93790
ICD-9 Code
V81.1 — Screening for hypertension
ICD-10 Code
Z136
HIGH BLOOD PRESSURE, SCREENING IN INFANTS, CHILDREN & ADOLESCENTS
HRSA (Bright Futures) Recommendation
Infants and children with specific risk factors for high blood pressure should be screened up through age 2½; blood pressure examination is included in the complete physical examination done routinely after 2½.
CPT/HCPCS Codes
CPT 99381 – 99384
CPT 99391 – 99394
HIV pre-exposure prophylaxis for the prevention of HIV infection:
The USPSTF recommends that clinicians offer pre-exposure prophylaxis (PrEP) with effective antiretroviral therapy to persons who are at high risk of HIV acquisition.
Additional guidance received in 2021 regarding PrEP:
Clinicians should offer pre-exposure prophylaxis (PrEP) with effective antiretroviral therapy to persons who are not infected with HIV and who are at high risk of HIV acquisition. The USPSTF recommends the following services to be received prior to being prescribed antiretroviral medication as part of the determination of whether PrEP is appropriate as well as ongoing follow-up and monitoring:
HIV testing at baseline and every three months while taking PrEP
Hepatitis B and C testing
Creatinine testing and calculated estimated creatinine clearance (eCrCL) or glomerular filtration rate (eGFR) to assess kidney function conducted both at baseline and periodically thereafter, consistent with CDC guidelines
Pregnancy testing, both at baseline and periodically thereafter
Sexually transmitted infection (STI) screening and counseling
Adherence counseling
Applicable ICD 10 diagnosis codes: Z11.3, Z11.4, Z720.2, Z720.6, Z71.7, Z72.51, Z72.52, Z725.3, Z77.21, Z2981
Applicable CPT codes: 80047, 80048, 80053, 80069, 81025, 82565, 82570, 82540, 84702
All other benefits can be found under Hepatitis, B and C, Human Immunodeficiency (HIV) and Sexually transmitted infection (STI) screening and counseling categories.
Pre-exposure prophylaxis (PrEP) with effective antiretroviral therapy is a pharmacy benefit.
HIV screening: Adolescents and adults ages 15 to 65 years
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
HCPCS G0432
HCPCS G0433
HCPCS G0435
HCPCS S3645
ICD-9 Codes
V01.79
V22.0 – V24.2
ICD-10 Codes
Z114
Z206
Z20828
Z34 – Z3493
Z331
Z717
Z7251 – Z7253
O0900 – O0993
Hypertension in Adults: Screening: adults 18 years or older without known hypertension:
The USPSTF recommends screening for hypertension in adults 18 years or older with office blood pressure measurement (OBPM). The USPSTF recommends obtaining blood pressure measurements outside of the clinical setting for diagnostic confirmation before starting treatment.
CPT:
Code with the appropriate evaluation and management code.
HYPOTHYROIDISM, SCREENING IN NEWBORNS
USPSTF Recommendation
The USPSTF recommends screening for congenital hypothyroidism in newborns. (Grade A)
HRSA (Bright Futures) Recommendation
This test is usually done prior to discharge from the hospital following birth of the infant.
CPT/HCPCS Code
CPT 84443 — Thyroid stimulating hormone (TSH)
ICD-9 Code
V77.0 — Screening for thyroid disorder
ICD-10 Code
Z1329
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 Code
CPT 99401
*Codes 99402 – 99404 will require record review.
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 (Grade B).
CPT/HCPCS Codes
CPT 80055
CPT 80081
CPT 85013
CPT 85014
CPT 85018
ICD-9 Codes
V22.0 – V23.9
ICD-10 Codes
Z34 – Z3493
Z331
O0900 – O0993
LEAD SCREENING IN INFANTS CHILDREN AND THROUGH AGE 6
HRSA (Bright Futures) Recommendation
Begin screening at the 6-month well-child visit for children who are positive on risk screening questions. Continue as routine screening for children from high prevalence area and screen selectively children from low prevalence areas.
CPT/HCPCS Code
CPT 83655
LIPID (CHOLESTEROL), SCREENING
USPSTF Recommendations
The USPSTF strongly recommends screening men aged 35 and older for lipid disorders. (Grade A)
The USPSTF recommends screening men aged 20 to 35 for lipid disorders if they are at increased risk for coronary heart disease. (Grade B)
The USPSTF strongly recommends screening women aged 45 and older for lipid disorders if they are at increased risk for coronary heart disease. (Grade A)
The USPSTF recommends screening women aged 20 to 45 for lipid disorders if they are at increased risk for coronary heart disease. (Grade B)
HRSA (Bright Futures) Recommendation
Begin screening with lipid profile for children who test positive on risk screening questions beginning at age 2. Screening would not be repeated unless the child or adolescent’s risk factors changed. If the risk factors change, screening could be repeated at 4 years, 6 years, 8 years, 10 years, between 11 and 14 years, between 15 and 17 years and between 18 and 21 years.
CPT/HCPCS Code
CPT 80061
ICD-9 Code
V77.91 — Screening for lipoid disorders
ICD-10 Code
Z13220
LUNG CANCER SCREENING, ADULTS
USPSTF Recommendation
The USPSTF recommends annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.
(Grade B)
CPT/HCPCS Codes
71250 with modifier 52
S8032 (effective Oct. 1, 2014)
G0296 (effective Jan. 1, 2016)
G0297 (effective Jan. 1, 2016)
71271 (effective Jan. 1, 2021)
ICD-9 Code
V76.0
ICD-10 Code
Z122
Newborn Bilirubin
Bright Futures recommends confirmation of initial bilirubin screening was accomplished, results verified and follow-up as appropriate are done.
CPT 82247 or 82248 during the first 28 days after birth indicate this service has been done.
NUTRITION (DIETARY) COUNSELING, ADULTS
USPSTF Recommendation
The USPSTF recommends offering or referring adults who are overweight or obese and have additional cardiovascular disease (CVD) risk factors to intensive behavior counseling interventions to promote a healthful diet and physical activity for CVD prevention. (Grade B)
The above verbiage was amended by the USPSTF November 2020 to state:
The USPSTF recommends offering or referring adults with cardiovascular disease risk factors to behavioral counseling interventions to promote a healthy diet and physical activity.
CPT/HCPCS Codes
CPT 97802 – 97804
HCPCS G0270
HCPCS S9470
ICD-9 Code
V65.3 — Dietary surveillance and counseling
ICD-10 Code
Z713
OBESITY IN ADULTS AND CHILDREN 6 YEARS OR OLDER; SCREENING AND COUNSELING
USPSTF Recommendation
Effective June 2012:
The USPSTF recommends screening all adults for obesity. Clinicians should offer or refer patients with a body mass index (BMI) of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions. (Grade B)
Prior to June 2012:
The USPSTF recommends that clinicians screen all adult patients and children 6 years or older for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese individuals. For children clinicians should offer then or refer them to comprehensive, intensive behavioral interventions to promote improvement in weight status. (Grade B)
Recommendation updated in June of 2017:
Obesity screening: Childhood and adolescents:
The USPSTF recommends that clinicians screen for obesity in children and adolescents 6 years and older and offer or refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status.
Effective June 2024 the USPSTF verbiage has been updated to state:
High Body Mass Index in Children and Adolescents: Interventions: children and adolescents 6 years or older:
The USPSTF recommends that clinicians provide or refer children and adolescents 6 years or older with a high body mass index (BMI) (>95 percentile for age and sex) to comprehensive, intensive behavioral interventions.
HRSA (Bright Futures — Anticipatory Guidance)
Bright Futures identifies healthy weight promotion as 1 of 2 critical themes within the guidelines. Recommendations in Bright Futures are consistent with the Prevention and Prevention Plus stages outlined in the Expert Committee Recommendations regarding the Prevention, Assessment, and Treatment of Child Adolescent Overweight and Obesity. This recommendation applies to children age 6 and above.
CPT/HCPCS Codes
CPT 99401
CPT 99402
HCPCS G0447
ICD-9 Code
V77.8 — Screening for obesity
ICD-10 Code
Z1389
OSTEOPOROSIS SCREENING IN WOMEN
USPSTF Recommendation
The USPSTF recommends screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in postmenopausal women younger than 65 years who are at increased risk of osteoporosis, as determined by a formal clinical risk assessment tool (grade B)
The USPSTF recommends screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in women 65 years and older. (grade B)
CPT/HCPCS Code
CPT 77080
ICD-9 Code
V82.81 — Special screening for osteoporosis
ICD-10 Code
Z13820
Perinatal depression: Counseling and intervention
USPSTF Recommendation
The USPSTF recommends that clinicians provide or refer pregnant and postpartum persons who are at increased risk of perinatal depression to counseling interventions.
CPT Code:
96160 administration of patient-focused health risk assessment instrument (e.g., health hazard appraisal) with scoring and documentation, per standardized instrument
USE OF -33 MODIFIER IS MANDATORY
ICD-9 code
V79.0 screening for depression
ICD-10 code
Z1332 — Encounter for screening for maternal depression
PHENYLKETONURIA SCREENING IN NEWBORNS
USPSTF Recommendation
The USPSTF recommends screening for phenylketonuria (PKU) in newborns. (Grade A)
HRSA (Bright Futures) Recommendation
This test is usually done prior to discharge from the hospital following birth of the infant.
CPT/HCPCS Code
CPT 84030
ICD-9 Code:
V77.7 — Screening for other inborn errors of metabolism
ICD-10 Code
Z13228
PRE-ECLAMPSIA PREVENTION ASPIRIN
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 recommendation:
The USPSTF recommends screening for preeclampsia in pregnant women with blood pressure measurements throughout pregnancy.
PSYCHOSOCIAL/BEHAVIORAL ASSESSMENT
Bright Futures recommendation that a psychosocial/behavioral assessment is completed that should be family-centered and may include an assessment of child social-emotional health, caregiver depression, and social determinants of health during preventive visits.
CPT 96127 — Brief emotional/behavioral assessment (e.g., depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument.
To indicate this service has been provided, CPT code 96127 should be filed in conjunction with the preventive visit codes: 99381 – 99384, 99391 – 99394, 99385 or 99395.
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/HCPCS Codes
CPT 80055
CPT 80081
CPT 86901
ICD-9 Codes
V22.0 – V23.9
ICD-10 Codes
Z34 – Z3493
Z331
O0900 – O0993
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
Both codes are anticipated to be filed to demonstrate this screening has been done.
SEXUALLY TRANSMITTED INFECTIONS (STI’s); BEHAVIORAL COUNSELING TO PREVENT
USPSTF Recommendation
The USPSTF recommends behavioral counseling for all sexually active adolescents and for adults who are at increased risk for sexually transmitted infections (STIs).
CPT/HCPCS 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
SKIN CANCER COUNSELING FOR PERSONS 6 – 24 YEARS
USPSTF Recommendation
The USPSTF recommends counseling young adults, adolescents, children, and parents of young children about minimizing exposure to ultraviolet (UV) radiation for persons aged 6 months to 24 years with fair skin types to reduce their risk of skin cancer. (Grade B)
CPT/HCPCS Code
CPT 99401
ICD-9 Code
V65.49
ICD-10 Code
Z7189
SICKLE CELL SCREENING DISEASE, NEWBORN SCREENING
USPSTF Recommendation
The USPSTF recommends screening for sickle cell disease in newborns. (Grade A)
HRSA (Bright Futures) Recommendation
This test is usually done prior to discharge from the hospital following birth of the infant.
CPT/HCPCS Codes
CPT 83020
CPT 83021
ICD-9 Codes
V30 – V30.9
V78.2
ICD-10 Codes
Z38 – Z38.8
Z130
STATIN PREVENTIVE MEDICATION:
The USPSTF recommends that adults without a history of cardiovascular disease (CVD) (i.e., symptomatic coronary artery disease or ischemic stroke) use a low- to moderate-dose statin for the prevention of CVD events and mortality when all of the following criteria are met: 1) they are ages 40 to 75 years; 2) they have 1 or more CVD risk factors (i.e., dyslipidemia, diabetes, hypertension, or smoking); and 3) they have a calculated 10-year risk of a cardiovascular event of 10% or greater. Identification of dyslipidemia and calculation of 10-year CVD event risk requires universal lipids screening in adults ages 40 to 75 years. (GRADE b)
Recommendation updated August, 2022 to read:
The USPSTF recommends that clinicians prescribe a statin for the primary prevention of CVD for adults aged 40 to 75 years who have 1 or more CVD risk factors (i.e., dyslipidemia, diabetes, hypertension, or smoking) and an estimated 10-year risk of a cardiovascular event of 10% or greater. Grade B
Covered medications include the following:
Atorvastatin 10 mg, 20 mg
Fluvastatin 20 mg, 40 mg
Fluvastatin ER 80 mg
Lovastatin 10 mg, 20 mg, 40 mg
Pravastatin 10 mg, 20 mg, 40 mg, 80 mg
Rosuvastatin 5 mg, 10 mg
Simvastatin 5 mg, 10 mg, 20 mg, 40 mg
SYPHILIS SCREENING
USPSTF Recommendation
The USPSTF recommends screening for syphilis infection in persons who are at increased risk for infection.
The USPSTF recommends early, universal screening for syphilis infection during pregnancy; if an individual is not screened early in pregnancy, USPSTF recommends screening at the first available opportunity.
HRSA (Bright Futures) Recommendation
Bright Futures recommends screening for syphilis in all adolescents who are sexually active and positive for high risk.
CPT/HCPCS Codes
CPT 80055
CPT 80081
CPT 86592
CPT 86780
ICD-9 Codes
V22.0 – V23.9
V69.2
V74.5
ICD-10 Codes
Z202
Z34 – Z3493
Z331
Z113
O0900 – O0993
Z7251 – Z7253
TOBACCO USE, SCREENING, COUNSELING AND INTERVENTIONS
USPSTF Recommendation
The USPSTF recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products. (Grade A)
The USPSTF recommends that clinicians ask all pregnant women about tobacco use and provide augmented, pregnancy-tailored counseling for those who smoke. (Grade A)
The USPSTF recommends that clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use in school-aged children.
These recommendations were restated in September 2015 to state:
Tobacco use counseling and interventions: nonpregnant adults
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
Tobacco use counseling: pregnant women 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 recommendation related to school aged children and tobacco was not altered.
April 2020 update to verbiage states:
The USPSTF recommends that primary care clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use among school-aged children and adolescents.
HRSA (Bright Futures) Recommendation
Bright Futures recommends that health care professionals screen for tobacco use and tobacco smoke exposure, encourage tobacco use cessation, and provide tobacco use cessation strategies and resources at most visits for school-aged children and adolescents ages 5 years and older.
CPT/HCPCS 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
O99300 – O99335
Z87891
Z779
Z9289
TUBERCUOLOSIS SCREENING: ADULT
The USPSTF recommends screening for latent tuberculosis infection in populations at increased risk.
CPT CODES
86480
86580
ICD-9 CODE
V741 — Screening examination for pulmonary tuberculosis
ICD-10 CODE
Z11.1 — Encounter for screening of respiratory tuberculosis
TUBERCULOSIS SCREENING PEDIATRIC
HRSA (Bright Futures) recommendation:
Screening for risk factors that would indicate high risk of tuberculosis should be performed at one month, 6 months, 12 months and then annually. If determined to be at high risk, testing should be performed.
CPT CODES:
86480
86580
ICD-9 CODE:
V741 — Screening examination for pulmonary tuberculosis
ICD-10 CODE:
Z11.1 — Encounter for screening of respiratory tuberculosis
Unhealthy alcohol use: adults
The USPSTF recommends screening for unhealthy alcohol use in primary care settings in adults 18 years or older, including pregnant women, and providing persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce unhealthy alcohol use.
CPT/HCPCS Codes
CPT 99408
HCPCS G0396
HCPCS G0443
ICD-9 Codes
V79.1 Screening for alcoholism
ICD-10 Codes
Z1389
Unhealthy Drug Use: Screening adults age 18 or older:
The USPSTF recommends screening by asking questions about unhealthy drug use in adults ages 18 years or older. Screening should be implemented when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred. (Screening refers to asking questions about unhealthy drug use, not testing biological specimens.)
VISUAL IMPAIRMENT, SCREENING IN CHILDREN
USPSTF Recommendation
The USPSTF recommends vision screening for all children at least once between the ages of 3 and 5 years by a non-eye care professional, to detect the presence of amblyopia or its risk factors (Grade B)
HRSA (Bright Futures) Recommendation
Selective screening of newborn, infants, and children through age 2, to assess for abnormal funduscopic examination, particularly if premature or other risk conditions.
CPT/HCPS Codes
CPT 99173
CPT 99174
CPT 99177
For members 6 years old and older, instrument-based ocular screening will be considered NOT MEDICALLY NECESSARY.
Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.
Reference
- Internet Citation: USPSTF A and B Recommendations, U.S. Preventive Services Task Force. August 2019 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, Blue Cross Blue Shield Association technology assessment program (TEC) 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"
History From 2024 Forward
| 01/02/2025 |
Annual review, no change to policy intent. |
| 11/01/2024 |
Added DX Z2981 to PrEp Section. No other changes made. |
| 06/26/2024 |
Interim review, effective 06/2024 the USPSTF recommends that clinicians provide or refer children and adolescents 6 years or older with a high body mass index (BMI) (> 95 percentile for age and sex) to comprehensive, intensive behavioral interventions. |
| 05/29/2024 |
Interim Review, effective 07012024 the coverage criteria for cardiovascular prevention related to low asprin use terminates as USPSTF decrease this recommendation to a C/D recommendation. |
| 01/01/2024 |
NEW POLICY |
