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Preventive Services
Due to the Patient Protection and Affordable Care Act (commonly referred to as federal health care reform), with the
exception of groups maintaining "grandfathered" status, all Tufts Health Plan plans are required to provide 100%
coverage for preventive care services. Grandfathered groups are not subject to this requirement, but many of these
groups have opted to cover preventive services with no cost sharing.
This means that members will have no cost-sharing responsibility when preventive services are rendered by an innetwork provider. Members may still be required to pay a copayment, deductible or coinsurance for preventive services
received from out-of-network providers (PPO and POS plans), or for non-preventive services received in conjunction with
a preventive services visit.
Preventive services identified in this policy are based on recommendations from the U.S. Preventive Services Task Force,
Bright Futures, American Academy of Pediatrics (AAP), Centers for Disease Control and Prevention (CDC) and Advisory
Committee for Immunization Practices (ACIP).
Tufts Health Plan accepts and recognizes the use of modifier 33 when billed with services on the U.S. Preventive Services
Task Force List that have an A or B rating. The American Medical Association created this modifier to allow providers to
identify a preventive service for which patient cost sharing does not apply under the Patient Protection and Affordable
Care Act, which prohibits patient cost sharing for non-grandfathered plans. Modifier 33 is appropriate to use with a CPT
code that is a diagnostic/treatment service being performed as a preventive service. Refer to the Modifier Payment
Policy for more information regarding modifiers.
Tufts Health Plan covers the women’s preventive health care services as indicated in the Woman’s Health section of this
document, with no cost share for most members when those services are rendered by a provider in the member’s plan
network. Please refer to the Woman’s Health section of this document for additional information.
Providers and their office staff are required to use self-service channels to verify effective dates and copayments for
commercial members prior to initiating services.
VENIPUNCTURE
The below CPT code is considered preventive when billed with Modifier 33 and/or when billed with one of the below
ICD-9 or ICD-10 codes:
CPT Code
Description
36415
Collection of venous blood by venipuncture
ICD-9 Diagnosis Code
V20.2
V20.31
V20.32
V22.0
V22.1
V22.2
V23.0
V23.1
V23.2
V23.3
V23.41
V23.49
V23.5
V23.7
V23.81
V23.82
V23.83
V23.84
V23.85
Revised 06/09/14
2163789
Description
Routine infant or child health check
Health supervision for newborn under 8 days old
Health supervision for newborn 8 to 28 days old
Supervision of normal pregnancy
Supervision of other than normal pregnancy
Pregnant state, incidental
Pregnancy with history of infertility
Pregnancy with history of trophoblastic disease
Pregnancy with history of abortion
Grand multiparity
Pregnancy with history of labor pre-term
Pregnancy with other poor obstetric history
Pregnancy with other poor reproductive history
Insufficient prenatal care
Elderly primigravida
Elderly multigravida
Young primigravida
Young multigravida
Pregnancy resulting from assisted reproductive technology
1
Preventive Services
ICD-9 Diagnosis Code
V23.86
V23.89
V23.9
V25.2
V70.0
V72.62
V77.1
V77.91
Description
Pregnancy with history of in-utero procedure during previous pregnancy
Other high-risk pregnancy
Unspecified high-risk pregnancy
Sterilization
Routine general medical examination at a health care facility
Laboratory examination ordered as part of a routine general medical examination
Diabetes mellitus
Screening for lipid disorders
The following ICD-10 codes are effective for dates of service on or after October 1, 2015:
ICD-9 Diagnosis Code
Description
O09.00 - O09.93
Supervision of high risk pregnancy
Z00.00
Encounter for general adult medical examination without abnormal findings
Z00.110
Health examination for newborn under 8 days old
Z00.111
Health examination for newborn 8 to 28 days old
Z00.129
Encounter for routine child health examination without abnormal findings
Z13.1
Encounter for screening for diabetes mellitus
Z13.220
Encounter for screening for lipoid disorders
Z30.2
Encounter for sterilization
Z33.1
Pregnant state, incidental
Z34.00 - Z34.93
Encounter for supervision of normal pregnancy
PREVENTIVE OFFICE VISITS
The below CPT codes are considered preventive:
CPT Code
Description
Initial comprehensive preventive medicine evaluation and management of an individual including an age
and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
99381
interventions, and the ordering of laboratory/diagnostic procedures, new patient; infant (age younger
than 1 year)
Initial comprehensive preventive medicine evaluation and management of an individual including an age
and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
99382
interventions, and the ordering of laboratory/diagnostic procedures, new patient; early childhood (age 1
through 4 years)
Initial comprehensive preventive medicine evaluation and management of an individual including an age
and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
99383
interventions, and the ordering of laboratory/diagnostic procedures, new patient; late childhood (age 5
through 11 years)
Initial comprehensive preventive medicine evaluation and management of an individual including an age
and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
99384
interventions, and the ordering of laboratory/diagnostic procedures, new patient; adolescent (age 12
through 17 years)
Initial comprehensive preventive medicine evaluation and management of an individual including an age
99385
and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures, new patient; 18-39 years
Initial comprehensive preventive medicine evaluation and management of an individual including an age
99386
and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures, new patient; 40-64 years
Initial comprehensive preventive medicine evaluation and management of an individual including an age
99387
and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures, new patient; 65 years and older
Revised 06/09/14
2
Preventive Services
CPT Code
99391
99392
99393
99394
99395
99396
99397
99460
99461
99462
99463
G0438
G0439
Description
Periodic comprehensive preventive medicine reevaluation and management of an individual including an
age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures, established patient; infant (age
younger than 1 year)
Periodic comprehensive preventive medicine reevaluation and management of an individual including an
age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures, established patient; early childhood
(age 1 through 4 years)
Periodic comprehensive preventive medicine reevaluation and management of an individual including an
age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures, established patient; late childhood
(age 5 through 11 years)
Periodic comprehensive preventive medicine reevaluation and management of an individual including an
age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age
12 through 17 years)
Periodic comprehensive preventive medicine reevaluation and management of an individual including an
age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18-39 years
Periodic comprehensive preventive medicine reevaluation and management of an individual including an
age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years
Periodic comprehensive preventive medicine reevaluation and management of an individual including an
age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and
older
Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant
Initial care, per day , for evaluation and management of normal newborn infant seen in other than
hospital or birthing center
Subsequent hospital care, per day, for evaluation and management of normal newborn
Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant
admitted and discharged on the same date
Annual wellness visit; includes a personalized prevention plan of service (PPS), initial visit
Annual wellness visit, includes a personalized prevention plan of service (PPS), subsequent visit
ROUTINE HEALTH SCREENINGS: ADULT
Abdominal Aortic Aneurysm: Men ages 65-75
The below CPT/HCPCS codes are considered preventive when billed with one of the following - ICD-9 codes V15.82
(Personal history of tobacco use, presenting hazards to health), V81.2 (Screening for other and unspecified
cardiovascular conditions) or ICD-10 codes Z13.6 (Encounter for screening for cardiovascular disorders), Z87.891
(Personal history of nicotine dependence):
CPT/HCPCS Code
Description
76700
Ultrasound, abdominal, real time with image documentation; complete
Ultrasound, abdominal, real time with image documentation; limited (e.g., single organ, quadrant,
76705
follow-up)
Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), real time with image documentation;
76770
complete
76775
Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), real time with image documentation; limited
Ultrasound B-scan and/or real time with image documentation; for abdominal aortic aneurysm
G0389
(AAA) screening
Revised 06/09/14
3
Preventive Services
Asymptomatic Bacteriuria, Rh (D) Blood Typing (first pregnancy related visit), Iron Deficiency Anemia Pregnant
Women
CPT codes 81000 (Urinalysis), 86901 (Blood typing; Rh (D)), 85025 (Blood count; complete) and 85027 (Blood count;
complete) are considered preventive when billed with one of the below ICD-9 or ICD-10 diagnosis codes:
ICD-9 Diagnosis Code
Description
V22.0
Supervision of normal pregnancy
V22.1
Supervision of other than normal pregnancy
V22.2
Pregnant state, incidental
V23.0
Pregnancy with history of infertility
V23.1
Pregnancy with history of trophoblastic disease
V23.2
Pregnancy with history of abortion
V23.3
Grand multiparity
V23.41
Pregnancy with history of labor pre-term
V23.49
Pregnancy with other poor obstetric history
V23.5
Pregnancy with other poor reproductive history
V23.7
Insufficient prenatal care
V23.81
Elderly primigravida
V23.82
Elderly multigravida
V23.83
Young primigravida
V23.84
Young multigravida
V23.85
Pregnancy resulting from assisted reproductive technology
V23.86
Pregnancy with history of in-utero procedure during previous pregnancy
V23.89
Other high-risk pregnancy
V23.9
Unspecified high-risk pregnancy
The following ICD-10 codes are effective for dates of service on or after October 1, 2015:
ICD-10 Diagnosis Code Description
O09.00 - O09.93
Supervision of high risk pregnancy
Z33.1
Pregnant state, incidental
Z34.00 - Z34.93
Encounter for supervision of normal pregnancy
Blood Pressure Screening: Adults ages 18 and older
Included in preventive evaluation and management visit
BRCA Genetic Testing*
The below CPT/HCPCS codes are considered preventive when billed with one of the following - ICD-9 codes V16.3
(Family history of malignant neoplasm, breast) or V16.41 (Family history of malignant neoplasm, genital organs, ovary)
or ICD-10 codes Z80.3 (Family history of malignant neoplasm of breast) or Z80.41 (Family history of malignant
neoplasm of ovary):
CPT/HCPCS Code
Description
BRCA1, BRCA2 (breast cancer 1 and 2) (e.g., hereditary breast and ovarian cancer) gene analysis; full
81211
sequence analysis and common duplication/deletion variants in BRCA1
BRCA1, BRCA2 (breast cancer 1 and 2) (e.g., hereditary breast and ovarian cancer) gene analysis;
81212
185delAG, 5385insC, 6174delT variants
BRCA1, BRCA2 (breast cancer 1 and 2) (e.g., hereditary breast and ovarian cancer) gene analysis;
81213
uncommon duplication/deletion variants
BRCA1 (breast cancer 1) (e.g., hereditary breast and ovarian cancer) gene analysis; full sequence
81214
analysis and common duplication/deletion variants
BRCA1 (breast cancer 1) (e.g., hereditary breast and ovarian cancer) gene analysis; known familial
81215
variant
BRCA2 (breast cancer 2) (e.g., hereditary breast and ovarian cancer) gene analysis; full sequence
81216
analysis
BRCA2 (breast cancer 2) (e.g., hereditary breast and ovarian cancer) gene analysis; known familial
81217
variant
Revised 06/09/14
4
Preventive Services
*Prior Authorization is required for BRCA Genetic Testing. Please refer to our Medical Necessity Guidelines.
Breast Cancer: Screening with Mammography ages 40 and older
The below CPT/HCPCS codes are considered preventive:
CPT/HCPCS Code
Description
Computer-aided detection (computer algorithm analysis of digital image data for lesion detection)
77052
with further physician review for interpretation, with or without digitization of film radiographic
images
77057
Screening mammography, bilateral (2-view film study of each breast)
G0202
Screening mammography, producing direct digital image, bilateral, all views
Cervical Cancer
The below CPT/HCPCS codes are considered preventive when billed with one of the following - ICD-9 code V76.2
(Screening for malignant neoplasm of the cervix) or ICD-10 code Z12.4 (Encounter for screening for malignant
neoplasm of cervix):
CPT/HCPCS Code
Description
88141
Cytopathology, cervical or vaginal (any reporting system), requiring interpretation by physician
Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated
88142
thin layer preparation; manual screening under physician supervision
88143
Cytopathology, cervical or vaginal (any reporting system)
88147
Cytopathology smears, cervical or vaginal; screening by automated system
88148
Cytopathology smears, cervical or vaginal; screening by automated system with manual rescreening
88150
Cytopathology, slides, cervical or vaginal; manual screening
88152
Cytopathology, slides, cervical or vaginal; with manual screening and computer-assisted rescreening
88153
Cytopathology, slides, cervical or vaginal; with manual screening and rescreening
Cytopathology, slides, cervical or vaginal; with manual screening and computer-assisted rescreening
88154
using cell selection and review
88155
Cytopathology, slides, cervical or vaginal, definitive hormonal evaluation
88164
Cytopathology, slides, cervical or vaginal (the Bethesda System); manual screening
Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and
88165
rescreening
Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and
88166
computer-assisted rescreening
Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and
88167
computer-assisted rescreening using cell selection and review
Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated
88174
thin layer preparation; screening by automated system
Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated
88175
thin layer preparation; with screening by automated system and manual rescreening or review
G0101
Cervical or vaginal cancer screening; pelvic and clinical breast examination
Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid,
G0123
automated thin layer preparation
Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid,
G0124
automated thin layer preparation, requiring interpretation by physician
Screening cytopathology smears, cervical or vaginal, performed by automated system, with manual
G0141
rescreening, requiring interpretation by physician
Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid,
G0143
automated thin layer preparation, with manual screening and rescreening
Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid,
G0144
automated thin layer preparation, with screening by automated system
Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid,
G0145
automated thin layer preparation, with screening by automated system and manual rescreening
G0147
Screening cytopathology smears, cervical or vaginal, performed by automated system
Revised 06/09/14
5
Preventive Services
CPT/HCPCS Code
G0148
Q0091
Description
Screening cytopathology smears, cervical or vaginal, performed by automated system with manual
rescreening
Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to
laboratory
Chlamydia and Gonorrhea: Women age 24 & younger or 25 & older at increased risk
The below CPT codes are considered preventive when billed with one of the following - ICD-9 code V74.5 (Screening
examination for venereal disease) or ICD-10 code Z11.3 (Encounter for screening for infections with a predominantly
sexual mode of transmission):
CPT Code
Description
87110
Culture, chlamydia, any source
87270
Infectious agent antigen detection by immunofluorescent technique
Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative,
87320
multiple-step method
87490
Infectious agent detection by nucleic acid (DNA or RNA); direct probe technique
87491
Infectious agent detection by nucleic acid (DNA or RNA); amplified probe technique
87492
Infectious agent detection by nucleic acid (DNA or RNA); quantification
Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, direct probe
87590
technique
Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe
87591
technique
Infectious agent antigen detection by immunoassay with direct optical observation; Neisseria
87850
gonorrhoeae
Colorectal Cancer: Adults ages 50-75
The below CPT/HCPCS codes are considered preventive when billed with one of the following - ICD-9 code V76.51
(Special screening for malignant neoplasms, colon) or ICD-10 code Z12.11 (Encounter for screening for malignant
neoplasm of colon):
CPT/HCPCS Code
Description
00810
Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum
Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen(s) by brushing or
45330
washing
45331
Sigmoidoscopy, flexible; with biopsy, single or multiple
45332
Sigmoidoscopy, flexible; with removal of foreign body
Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps
45333
or bipolar cautery
Sigmoidoscopy, flexible; with control of bleeding (e.g., injection, bipolar cautery, unipolar cautery,
45334
laser, heater probe, stapler, plasma coagulator)
45335
Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance
45337
Sigmoidoscopy, flexible; with decompression of volvulus, any method
45338
Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to
45339
removal by hot biopsy forceps, bipolar cautery or snare technique
45340
Sigmoidoscopy, flexible; with dilation by balloon, 1 or more strictures
45341
Sigmoidoscopy, flexible; with endoscopic ultrasound examination
Sigmoidoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine
45342
needle aspiration/biopsy(s)
45355
Colonoscopy, rigid or flexible, transabdominal via colotomy, single or multiple
Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of
45378
specimen(s) by brushing or washing, with or without colon decompression (separate procedure
45379
Colonoscopy, flexible, proximal to splenic flexure; with removal of foreign body
45380
Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple
Revised 06/09/14
6
Preventive Services
CPT/HCPCS Code
45381
45382
45383
45384
45385
45386
45387
45391
45392
74263
82270
82274
G0104
G0105
G0106
G0120
G0121
G0122
Description
Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any
substance
Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding (e.g., injection, bipolar
cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)
Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other
lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique
Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other
lesion(s) by hot biopsy forceps or bipolar cautery
Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other
lesion(s) by snare technique
Colonoscopy, flexible, proximal to splenic flexure; with dilation by balloon, 1 or more strictures
Colonoscopy, flexible, proximal to splenic flexure; with transendoscopic stent placement (includes
predilation)
Colonoscopy, flexible, proximal to splenic flexure; with endoscopic ultrasound examination
Colonoscopy, flexible, proximal to splenic flexure; with transendoscopic ultrasound guided
intramural or transmural fine needle aspiration/biopsy(s)
Computed tomographic (CT) colonography, screening, including image postprocessing
Blood, occult, by peroxidase activity (e.g., guaiac), qualitative; feces, consecutive collected
specimens with single determination, for colorectal neoplasm screening
Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3
simultaneous determinations
Colorectal cancer screening; flexible sigmoidoscopy
Colorectal cancer screening; colonoscopy on individual at high risk
Colorectal cancer screening; alternative to G0104, screening sigmoidoscopy, barium enema
Colorectal cancer screening; alternative to G0105, screening colonoscopy, barium enema
Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk
Colorectal cancer screening; barium enema
Depression: Adults ages 18 and older
The below CPT/HCPCS codes are considered preventive:
CPT Code
Description
Initial comprehensive preventive medicine evaluation and management of an individual including an age
99385
and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures, new patient; 18-39 years
Initial comprehensive preventive medicine evaluation and management of an individual including an age
99386
and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures, new patient; 40-64 years
Initial comprehensive preventive medicine evaluation and management of an individual including an age
99387
and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures, new patient; 65 years and older
Periodic comprehensive preventive medicine reevaluation and management of an individual including an
99395
age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18-39 years
Periodic comprehensive preventive medicine reevaluation and management of an individual including an
99396
age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years
Periodic comprehensive preventive medicine reevaluation and management of an individual including an
age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
99397
interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and
older
G0444
Annual depression screening, 15 minutes
Revised 06/09/14
7
Preventive Services
Hepatitis B Virus: Pregnant women
The below CPT codes are considered preventive when billed with one of the below ICD-9 or ICD-10 codes:
CPT Code
Description
86704
Hepatitis B core antibody (HBcAb); total
86706
Hepatitis B surface antibody (HBsAb)
86707
Hepatitis Be antibody (HBeAb)
ICD-9 Diagnosis Code
V22.0
V22.1
V22.2
V23.0
V23.1
V23.2
V23.3
V23.41
V23.49
V23.5
V23.7
V23.81
V23.82
V23.83
V23.84
V23.85
V23.86
V23.89
V23.9
Description
Supervision of normal pregnancy
Supervision of other than normal pregnancy
Pregnant state, incidental
Pregnancy with history of infertility
Pregnancy with history of trophoblastic disease
Pregnancy with history of abortion
Grand multiparity
Pregnancy with history of labor pre-term
Pregnancy with other poor obstetric history
Pregnancy with other poor reproductive history
Insufficient prenatal care
Elderly primigravida
Elderly multigravida
Young primigravida
Young multigravida
Pregnancy resulting from assisted reproductive technology
Pregnancy with history of in-utero procedure during previous pregnancy
Other high-risk pregnancy
Unspecified high-risk pregnancy
The following ICD-10 codes are effective for dates of service on or after October 1, 2015:
ICD-10 Diagnosis Code Description
O09.00 - O09.93
Supervision of high risk pregnancy
Z33.1
Pregnant state, incidental
Z34.00 - Z34.93
Encounter for supervision of normal pregnancy
Hepatitis C Virus: Persons at high risk for infection or a one-time screening for adults born between 1945 and 1965
The below CPT code is considered preventive:
CPT Code
Description
86803
Hepatitis C antibody
HIV: Adolescents and adults at increased risk and Pregnant Women
HIV screenings should be performed in adolescents and adults ages 15-65. Younger adolescents and older adults should
be screened if they're at a higher risk. The below CPT codes are considered preventive:
CPT Code
Description
86689
Antibody; HTLV or HIV antibody, confirmatory test (e.g., Western Blot)
86701
Antibody; HIV-1
86702
Antibody; HIV-2
86703
Antibody; HIV-1 and HIV-2, single assay
Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative,
87390
multiple-step method; HIV-1
Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative,
87391
multiple-step method; HIV-2
Revised 06/09/14
8
Preventive Services
Lipid Disorders in Adults: Men ages 35 and older, Men ages 20-34 with an increased risk for coronary heart disease
(CHD), Women ages 45 and older, and Women ages 20-44 with an increased risk for CHD
The below CPT codes are considered preventive when billed with one of the following - ICD-9 code V77.91 (Screening for
lipoid disorders) or ICD-10 code Z13.220 (Encounter for screening for lipoid disorders):
CPT Code
Description
80061
Lipid panel
82465
Cholesterol, serum or whole blood, total
83718
Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol)
83719
Lipoprotein, direct measurement; VLDL cholesterol
83721
Lipoprotein, direct measurement; LDL cholesterol
84478
Triglycerides
Lung Cancer Screening: Adults ages 55 to 80 who have a 30 pack-year smoking history and currently smoke or have
quit within the past 15 years
The below HCPCS code is considered preventive when billed with one of the following - ICD-9 code V15.82 (History of
tobacco use) or V76.0 (Special screening for malignant neoplasms, respiratory organs) or ICD-10 code Z87.891
(Personal history of nicotine dependence) or Z12.2 (Encounter for screening for malignant neoplasm of respiratory
organs):
HCPCS Code Description
S8092
Electron beam computed tomography (also known as Ultrafast CT, Cine CT)
Obesity Screening: Adults
The below CPT codes are considered preventive:
CPT Code
Description
Initial comprehensive preventive medicine evaluation and management of an individual including an
age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor
99385
reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 18-39
years
Initial comprehensive preventive medicine evaluation and management of an individual including an
age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor
99386
reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 40-64
years
Initial comprehensive preventive medicine evaluation and management of an individual including an
age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor
99387
reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 65 years
and older
Periodic comprehensive preventive medicine reevaluation and management of an individual including
an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor
99395
reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 1839 years
Periodic comprehensive preventive medicine reevaluation and management of an individual including
an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor
99396
reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 4064 years
Periodic comprehensive preventive medicine reevaluation and management of an individual including
an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor
99397
reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65
years and older
Osteoporosis: Postmenopausal Women ages 65 and older with no risk factors or ages 60 and older with risk factors
The below CPT codes are considered preventive:
CPT Code
Description
Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (e.g., hips, pelvis,
77078
spine)
Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (e.g., hips,
77080
pelvis, spine)
Revised 06/09/14
9
Preventive Services
CPT Code
77081
77082
Description
Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; appendicular skeleton
(peripheral) (e.g., radius, wrist, heel)
Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; vertebral fracture
assessment
Screening for Gonorrhea and Syphilis (Pregnant Women)
The below CPT codes are considered preventive when billed with one of the below ICD-9 or ICD-10 codes:
CPT Code
Description
86592
Syphilis test, non-treponemal antibody; qualitative
87590
Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, direct probe technique
Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe
87591
technique
87850
Infectious agent antigen detection by immunoassay with direct optical observation; Neisseria gonorrhoeae
ICD-9 Diagnosis Code
V22.0
V22.1
V22.2
V23.0
V23.1
V23.2
V23.3
V23.41
V23.49
V23.5
V23.7
V23.81
V23.82
V23.83
V23.84
V23.85
V23.86
V23.89
V23.9
Description
Supervision of normal pregnancy
Supervision of other than normal pregnancy
Pregnant state, incidental
Pregnancy with history of infertility
Pregnancy with history of trophoblastic disease
Pregnancy with history of abortion
Grand multiparity
Pregnancy with history of labor pre-term
Pregnancy with other poor obstetric history
Pregnancy with other poor reproductive history
Insufficient prenatal care
Elderly primigravida
Elderly multigravida
Young primigravida
Young multigravida
Pregnancy resulting from assisted reproductive technology
Pregnancy with history of in-utero procedure during previous pregnancy
Other high-risk pregnancy
Unspecified high-risk pregnancy
The following ICD-10 codes are effective for dates of service on or after October 1, 2015:
ICD-10 Diagnosis Code Description
O09.00 - O09.93
Supervision of high risk pregnancy
Z11.3
Encounter for screening for infections with a predominantly sexual mode of transmission
Z33.1
Pregnant state, incidental
Z34.00 - Z34.93
Encounter for supervision of normal pregnancy
Sexually Transmitted Infections (STI) Screening
The below CPT codes are considered preventive:
CPT Code
Description
87270
Infectious agent antigen detection by immunofluorescent technique; Chlamydia trachomatis
Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative,
87320
multiple-step method; Chlamydia trachomatis
86255
Fluorescent noninfectious agent antibody; screen, each antibody
86256
Fluorescent noninfectious agent antibody; titer, each antibody
86592
Syphilis test, non-treponemal antibody; qualitative
Revised 06/09/14
10
Preventive Services
CPT Code
86689
86701
86702
86703
Description
Antibody; HTLV or HIV antibody, confirmatory test (e.g., Western Blot)
Antibody; HIV-1
Antibody; HIV-2
Antibody; HIV-1 and HIV-2, single assay
Syphilis: Men and Women at increased risk
The below CPT code is considered preventive when billed with one of the following - ICD-9 code V74.5 (Screening
examination for venereal disease) or ICD-10 code Z11.3 (Encounter for screening for infections with a predominantly
sexual mode of transmission):
CPT Code
Description
86592
Syphilis test, non-treponemal antibody; qualitative (e.g., VDRL, RPR, ART)
Type 2 Diabetes Mellitus: Men and Women - Sustained BP 135/80+
The below CPT codes are considered preventive when billed with one of the following - ICD-9 code V77.1 (Screening for
diabetes mellitus) or ICD-10 code Z13.1 (Encounter for screening for diabetes mellitus):
CPT Code
Description
82947
Glucose; quantitative, blood (except reagent strip)
82948
Glucose; blood, reagent strip
ROUTINE HEALTH SCREENINGS: PEDIATRIC
Congenital Hypothyroidism Screening: Newborns
Included in inpatient evaluation and management services for newborns
Depression: Adolescents ages 12-17
The below CPT/HCPCS codes are considered preventive:
CPT Code
Description
Initial comprehensive preventive medicine evaluation and management of an individual including an age
and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
99384
interventions, and the ordering of laboratory/diagnostic procedures, new patient; adolescent (age 12
through 17 years)
Periodic comprehensive preventive medicine reevaluation and management of an individual including an
age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
99394
interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age
12 through 17 years)
G0444
Annual depression screening, 15 minutes
Developmental/Behavioral Assessment
In addition to the above CPT codes, the below CPT code is considered preventive:
CPT Code
Description
Developmental testing; limited (e.g., Developmental Screening Test II, Early Language Milestone
96110
Screen), with interpretation and report
Dyslipidemia
The below CPT codes are considered preventive when billed with one of the following - ICD-9 code V77.91 (Screening for
lipoid disorders) or ICD-10 code Z13.220 (Encounter for screening for lipoid disorders):
CPT Code
Description
80061
Lipid panel
82465
Cholesterol, serum or whole blood, total
83718
Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol)
83719
Lipoprotein, direct measurement; VLDL cholesterol
83721
Lipoprotein, direct measurement; LDL cholesterol
84478
Triglycerides
Hearing Loss Screening: Newborns
Included in inpatient evaluation and management services for newborns
Revised 06/09/14
11
Preventive Services
Hemocrit or Hemoglobin
The below CPT codes are considered preventive:
CPT Code
Description
85014
Blood count; hematocrit
85018
Blood count; hemoglobin
85013
Blood count; spun microhematocrit
Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated
85025
differential WBC count
85027
Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count)
Lead
The below CPT code is considered preventive when billed with one of the following - ICD-9 code V82.5 (Screening for
chemical poisoning and other contamination) or ICD-10 code Z13.88 (Encounter for screening for disorder due to
exposure to contaminants):
CPT Code
Description
83655
Lead
Metabolic/Hemoglobin Screening: Newborns
The below CPT codes are considered preventive:
CPT Code
Description
Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated
85025
differential WBC count
85018
Blood count; hemoglobin
85013
Blood count; spun microhematocrit
Obesity Screening: Children and Adolescents ages 6-17
The below CPT codes are considered preventive:
CPT Code
Description
Initial comprehensive preventive medicine evaluation and management of an individual including an age
and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
99383
interventions, and the ordering of laboratory/diagnostic procedures, new patient; late childhood (age 5
through 11 years)
Initial comprehensive preventive medicine evaluation and management of an individual including an age
and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
99384
interventions, and the ordering of laboratory/diagnostic procedures, new patient; adolescent (age 12
through 17 years)
Periodic comprehensive preventive medicine reevaluation and management of an individual including an
age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
99393
interventions, and the ordering of laboratory/diagnostic procedures, established patient; late childhood
(age 5 through 11 years)
Periodic comprehensive preventive medicine reevaluation and management of an individual including an
age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
99394
interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age
12 through 17 years)
Phenylketonuria Screening: Newborns
Included in inpatient evaluation and management services for newborns
Skin Cancer Behavioral Counseling: Children, Adolescents and Young Adults ages 10 to 24
Included in preventive evaluation and management visit
Tuberculin Test
The below CPT codes are considered preventive:
CPT Code
Description
86580
Skin test; tuberculosis, intradermal
86480
Tuberculosis test, cell mediated immunity measurement of gamma interferon antigen response
Revised 06/09/14
12
Preventive Services
Visual Acuity Screening: Children ages 3 to 5
The below CPT code is considered preventive:
CPT Code
Description
99173
Screening test of visual acuity, quantitative, bilateral
Visual Impairment: Children younger than 5
The below CPT codes are considered preventive:
CPT Code
Description
Initial comprehensive preventive medicine evaluation and management of an individual including an age
and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
99381
interventions, and the ordering of laboratory/diagnostic procedures, new patient; infant (age younger
than 1 year)
Initial comprehensive preventive medicine evaluation and management of an individual including an age
and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
99382
interventions, and the ordering of laboratory/diagnostic procedures, new patient; early childhood (age 1
through 4 years)
Periodic comprehensive preventive medicine reevaluation and management of an individual including an
age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
99391
interventions, and the ordering of laboratory/diagnostic procedures, established patient; infant (age
younger than 1 year)
Periodic comprehensive preventive medicine reevaluation and management of an individual including an
age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
99392
interventions, and the ordering of laboratory/diagnostic procedures, established patient; early childhood
(age 1 through 4 years)
PREVENTIVE IMMUNIZATIONS
All immunizations are subject to availability. Refer to our List of Unavailable Vaccines and Drugs policy for additional
information.
Pediatric and Adolescent Immunizations
The below pediatric and adolescent immunizations are considered preventive:
Immunization/Vaccine
CPT Code
Description
Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), when
90700
administered to individuals younger than 7 years, for intramuscular use
Diphtheria and tetanus toxoids (DT) adsorbed when administered to
90702
individuals younger than 7 years, for intramuscular use
DTP
Tetanus and diphtheria toxoids (Td) adsorbed, preservative free, when
90714
administered to individuals 7 years or older, for intramuscular use
Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when
90715
administered to individuals 7 years or older, for intramuscular use
90719
Diphtheria toxoid, for intramuscular use
Hemophilus influenza b vaccine (Hib), HbOC conjugate (4 dose schedule),
90645
for intramuscular use
Hemophilus influenza b vaccine (Hib), PRP-D conjugate, for booster use
90646
only, intramuscular use
Hemophilus Influenza Type B
Hemophilus influenza b vaccine (Hib), PRP-T conjugate (4 dose schedule),
90647
for intramuscular use
Hemophilus influenza b vaccine (Hib), PRP-T conjugate (4 dose schedule),
90648
for intramuscular use
Hepatitis A vaccine, pediatric/adolescent dosage-2 dose schedule, for
90633
intramuscular use
Hepatitis A
Hepatitis A vaccine, pediatric/adolescent dosage-3 dose schedule, for
90634
intramuscular use
Hepatitis B
90743
Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use
Revised 06/09/14
13
Preventive Services
Immunization/Vaccine
CPT Code
90744
90649
HPV: ages 9-26
90650
Inactivated Poliovirus
90713
Q2035
Q2036
Q2037
Q2038
Q2039
90653
90654
90655
90656
Influenza
90657
90658
90660
90661
90662
90664
90672
90673
90688
90644
Meningococcal
90733
90734
MMR (Measles, Mumps,
Rubella)
MMRV (Measles, mumps,
rubella, and varicella)
Revised 06/09/14
90707
90710
Description
Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for
intramuscular use
Human Papilloma virus (HPV) vaccine, types 6, 11, 16, 18 (quadrivalent), 3
dose schedule, for intramuscular use
Human Papilloma virus (HPV) vaccine, types 16, 18, bivalent, 3 dose
schedule, for intramuscular use
Poliovirus vaccine, inactivated (IPV), for subcutaneous or intramuscular
use
Influenza virus vaccine, split virus, when administered to individuals 3
years of age and older, for intramuscular use (AFLURIA)
Influenza virus vaccine, split virus, when administered to individuals 3
years of age and older, for intramuscular use (FLULAVAL)
Influenza virus vaccine, split virus, when administered to individuals 3
years of age and older, for intramuscular use (FLUVIRIN)
Influenza virus vaccine, split virus, when administered to individuals 3
years of age and older, for intramuscular use (Fluzone)
Influenza virus vaccine, split virus, when administered to individuals 3
years of age and older, for intramuscular use (not otherwise specified)
Influenza vaccine, inactivated, subunit, adjuvanted, for intramuscular use
Influenza virus vaccine, split virus, preservative-free, for intradermal use
Influenza virus vaccine, split virus, preservative-free, when administered
to children 6-35 months of age, for intramuscular use
Influenza virus vaccine, split virus, preservative-free, when administered
to individuals 3 years and older, for intramuscular use
Influenza virus vaccine, split virus, when administered to children 6-35
months of age, for intramuscular use
Influenza virus vaccine, split virus, when administered to individuals 3
years of age and older, for intramuscular use
Influenza virus vaccine, live, for intranasal use
Influenza virus vaccine, derived from cell cultures, subunit, preservative
and antibiotic free, for intramuscular use
Influenza virus vaccine, split virus, preservative free, enhanced
immunogenicity via increased antigen content, for intramuscular use
Influenza virus vaccine, pandemic formulation, live, for intranasal use
Influenza virus vaccine, quadrivalent, live, for intranasal use
Influenza virus vaccine, trivalent, derived from recombinant DNA (RIV3),
hemagglutinin (HA) protein only, preservative and antibiotic free, for
intramuscular use
Influenza virus vaccine, quadrivalent, split virus, when administered to
individuals 3 years of age and older, for intramuscular use
Meningococcal conjugate vaccine, serogroups C & Y and Hemophilus
influenza b vaccine, tetanus toxoid conjugate (Hib-MenCY-TT), 4-dose
schedule, when administered to children 2-15 months of age, for
intramuscular use
Meningococcal polysaccharide vaccine (any group(s)), for subcutaneous
use
Meningococcal conjugate vaccine, serogroups A, C, Y and W-135
(tetravalent), for intramuscular use
Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous
use
Measles, mumps, rubella, and varicella vaccine (MMRV), live, for
subcutaneous use
14
Preventive Services
Immunization/Vaccine
Rotavirus
Varicella
CPT Code
90680
90681
90716
Description
Rotavirus vaccine, pentavalent, 3 dose schedule, live, for oral use
Rotavirus vaccine, human, attenuated, 2 dose schedule, live, for oral use
Varicella virus vaccine, live, for subcutaneous use
Adult Immunizations
The following adult immunizations are considered preventive:
Immunization/Vaccine
CPT Code
Description
Tetanus and diphtheria toxoids (Td) adsorbed, preservative free, when
90714
administered to individuals 7 years or older, for intramuscular use
Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when
90715
administered to individuals 7 years or older, for intramuscular use
DTP
Tetanus and diphtheria toxoids (Td) adsorbed when administered to
90718
individuals 7 years or older, for intramuscular use
90719
Diphtheria toxoid, for intramuscular use
Hepatitis A
90632
Hepatitis A vaccine, adult dosage, for intramuscular use
90739
Hepatitis B vaccine, adult dosage (2 dose schedule), for intramuscular use
90746
Hepatitis B vaccine, adult dosage, for intramuscular use
Hepatitis B
Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose
90747
schedule), for intramuscular use
Hepatitis A and hepatitis B vaccine (HepA-HepB), adult dosage, for
Hepatitis A and B
90636
intramuscular use
Human Papilloma virus (HPV) vaccine, types 6, 11, 16, 18 (quadrivalent), 3
90649
dose schedule, for intramuscular use
HPV: ages 9-26
Human Papilloma virus (HPV) vaccine, types 16, 18, bivalent, 3 dose
90650
schedule, for intramuscular use
90653
Influenza vaccine, inactivated, subunit, adjuvanted, for intramuscular use
90654
Influenza virus vaccine, split virus, preservative-free, for intradermal use
Influenza virus vaccine, split virus, preservative free, when administered
90656
to individuals 3 years and older, for intramuscular use
Influenza virus vaccine, split virus, when administered to individuals 3
90658
years of age and older, for intramuscular use
90660
Influenza virus vaccine, live, for intranasal use
Influenza virus vaccine, derived from cell cultures, subunit, preservative
90661
and antibiotic free, for intramuscular use
Influenza virus vaccine, split virus, preservative free, enhanced
90662
immunogenicity via increased antigen content, for intramuscular use
90672
Influenza virus vaccine, quadrivalent, live, for intranasal use
Influenza virus vaccine, trivalent, derived from recombinant DNA (RIV3),
Influenza
90673
hemagglutinin (HA) protein only, preservative and antibiotic free, for
intramuscular use
Influenza virus vaccine, quadrivalent, split virus, when administered to
90688
individuals 3 years of age and older, for intramuscular use
Influenza virus vaccine, split virus, when administered to individuals 3
Q2035
years of age and older, for intramuscular use (AFLURIA)
Influenza virus vaccine, split virus, when administered to individuals 3
Q2036
years of age and older, for intramuscular use (FLULAVAL)
Influenza virus vaccine, split virus, when administered to individuals 3
Q2037
years of age and older, for intramuscular use (FLUVIRIN)
Influenza virus vaccine, split virus, when administered to individuals 3
Q2038
years of age and older, for intramuscular use (Fluzone)
Influenza virus vaccine, split virus, when administered to individuals 3
Q2039
years of age and older, for intramuscular use (not otherwise specified)
Revised 06/09/14
15
Preventive Services
Immunization/Vaccine
CPT Code
90733
Meningococcal
90734
MMR (Measles, Mumps,
Rubella)
MMRV (Measles, mumps,
rubella, and varicella)
Pneumoccocal
(polysaccharide)
Varicella
Zoster
90707
90710
90669
90670
90732
90716
90736
Description
Meningococcal polysaccharide vaccine (any group(s)), for subcutaneous
use
Meningococcal conjugate vaccine, serogroups A, C, Y and W-135
(tetravalent), for intramuscular use
Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous
use
Measles, mumps, rubella, and varicella vaccine (MMRV), live, for
subcutaneous use
Pneumococcal conjugate vaccine, 7 valent, for intramuscular use
Pneumococcal conjugate vaccine, 13 valent, for intramuscular use
Pneumococcal polysaccharide vaccine, 23-valent, adult or
immunosuppressed patient dosage, when administered to individuals 2
years or older, for subcutaneous or intramuscular use
Varicella virus vaccine, live, for subcutaneous use
Zoster (shingles) vaccine, live, for subcutaneous injection
Preventive Immunization Administration Codes
The below CPT codes are considered preventive:
CPT Code
Description
Immunization administration through 18 years of age via any route of administration, with counseling
90460
by physician or other qualified health care professional; first vaccine/toxoid component
Immunization administration through 18 years of age via any route of administration, with counseling
90461
by physician or other qualified health care professional; each additional vaccine/toxoid component
(List separately in addition to code for primary procedure)
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular
90471
injections); 1 vaccine (single or combination vaccine/toxoid)
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular
90472
injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition
to code for primary procedure)
Immunization administration by intranasal or oral route; 1 vaccine (single or combination
90473
vaccine/toxoid)
Immunization administration by intranasal or oral route; each additional vaccine (single or combination
90474
vaccine/toxoid) (List separately in addition to code for primary procedure)
COUNSELING SERVICES
Alcohol Misuse: Screening and Behavioral Counseling for Adults
The below CPT/HCPCS codes are considered preventive:
CPT Code
Description
Alcohol and/or substance (other than tobacco) abuse structured screening (e.g., AUDIT, DAST), and brief
99408
intervention (SBI) services; 15 to 30 minutes
Alcohol and/or substance (other than tobacco) abuse structured screening (e.g., AUDIT, DAST), and brief
99409
intervention (SBI) services; greater than 30 minutes
G0442
Annual alcohol misuse screening, 15 minutes
G0443
Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes
Aspirin Counseling: Men ages 45 to 79 (for the prevention of myocardial infarctions), and Women ages 55 to 78 (for
the prevention of ischemic strokes)
The below CPT codes are considered preventive:
CPT Code
Description
Initial comprehensive preventive medicine evaluation and management of an individual including an age
99386
and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures, new patient; 40-64 years
Revised 06/09/14
16
Preventive Services
CPT Code
99387
99396
99397
Description
Initial comprehensive preventive medicine evaluation and management of an individual including an age
and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures, new patient; 65 years and older
Periodic comprehensive preventive medicine reevaluation and management of an individual including an
age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years
Periodic comprehensive preventive medicine reevaluation and management of an individual including an
age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and
older
BRCA Genetic Counseling
The below CPT/HCPCS codes are considered preventive when billed with one of the following - ICD-9 code V16.3 (Family
history of malignant neoplasm, breast) or V16.41 (Family history of malignant neoplasm, genital organs, ovary) or ICD10 code Z80.3 (Family history of malignant neoplasm of breast) or Z80.41 (Family history of malignant neoplasm of
ovary):
CPT/HCPCS Code
Description
96040
Medical genetics and genetic counseling services, each 30 minutes face-to-face with patient/family
S0265
Genetic counseling, under physician supervision, each 15 minutes
Healthy Diet: Counseling - Adults with hyperlipidemia and other risk factors for cardiovascular disease and dietrelated chronic disease
The below CPT/HCPCS codes are considered preventive:
CPT Code
Description
Initial comprehensive preventive medicine evaluation and management of an individual including an age
99385
and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures, new patient; 18-39 years
Initial comprehensive preventive medicine evaluation and management of an individual including an age
99386
and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures, new patient; 40-64 years
Initial comprehensive preventive medicine evaluation and management of an individual including an age
99387
and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures, new patient; 65 years and older
Periodic comprehensive preventive medicine reevaluation and management of an individual including an
99395
age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18-39 years
Periodic comprehensive preventive medicine reevaluation and management of an individual including an
99396
age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years
Periodic comprehensive preventive medicine reevaluation and management of an individual including an
age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
99397
interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and
older
Intensive behavioral therapy to reduce cardiovascular disease risk, individual, face-to-face, annual, 15
G0446
minutes
Obesity: Counseling
The below CPT/HCPCS codes are considered preventive:
CPT Code
Description
Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual
99401
(separate procedure); approximately 15 minutes
Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual
99402
(separate procedure); approximately 30 minutes
Revised 06/09/14
17
Preventive Services
CPT Code
99403
99404
G0447
Description
Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual
(separate procedure); approximately 45 minutes
Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual
(separate procedure); approximately 60 minutes
Face-to-face behavioral counseling for obesity, 15 minutes
Prenatal: Counseling
The below CPT codes are considered preventive:
CPT Code
Description
Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual
99401
(separate procedure); approximately 15 minutes
Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual
99402
(separate procedure); approximately 30 minutes
Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual
99403
(separate procedure); approximately 45 minutes
Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual
99404
(separate procedure); approximately 60 minutes
Tobacco Use: Counseling and intervention for Children, Adolescents and Adults (including Pregnant Women)
The below CPT/HCPCS codes are considered preventive:
CPT Code
Description
Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3
G0436
minutes, up to 10 minutes
Smoking and tobacco cessation counseling visit for the asymptomatic patient; intensive, greater than 10
G0437
minutes
S9453
Smoking cessation classes, non-physician provider, per session
Physician educational services rendered to patients in a group setting (e.g., prenatal, obesity, or diabetic
99078
instructions)
Initial comprehensive preventive medicine evaluation and management of an individual including an age
and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
99383
interventions, and the ordering of laboratory/diagnostic procedures, new patient; late childhood (age 5
through 11 years)
Initial comprehensive preventive medicine evaluation and management of an individual including an age
and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
99384
interventions, and the ordering of laboratory/diagnostic procedures, new patient; adolescent (age 12
through 17 years)
Initial comprehensive preventive medicine evaluation and management of an individual including an age
99385
and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures, new patient; 18-39 years
Initial comprehensive preventive medicine evaluation and management of an individual including an age
99386
and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures, new patient; 40-64 years
Initial comprehensive preventive medicine evaluation and management of an individual including an age
99387
and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures, new patient; 65 years and older
Periodic comprehensive preventive medicine reevaluation and management of an individual including an
age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
99393
interventions, and the ordering of laboratory/diagnostic procedures, established patient; late childhood
(age 5 through 11 years)
Periodic comprehensive preventive medicine reevaluation and management of an individual including an
age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
99394
interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age
12 through 17 years)
Revised 06/09/14
18
Preventive Services
CPT Code
99395
99396
99397
99406
99407
Description
Periodic comprehensive preventive medicine reevaluation and management of an individual including an
age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18-39 years
Periodic comprehensive preventive medicine reevaluation and management of an individual including an
age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years
Periodic comprehensive preventive medicine reevaluation and management of an individual including an
age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and
older
Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10
minutes
Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes
Sexually Transmitted Infections: Behavioral Counseling - Sexually Active Adolescents and Adults at increased risk
The below CPT/HCPCS codes are considered preventive:
CPT Code
Description
Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual
99401
(separate procedure); approximately 15 minutes
Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual
99402
(separate procedure); approximately 30 minutes
Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual
99403
(separate procedure); approximately 45 minutes
Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual
99404
(separate procedure); approximately 60 minutes
High intensity behavioral counseling to prevent sexually transmitted infection; face-to-face, individual,
G0445
includes: education, skills training and guidance on how to change sexual behavior; performed semiannually, 30 minutes
PHARMACY
U.S. Preventive Services Task Force A & B Recommendation Medications
Tufts Health Plan has included certain categories of medications in the preventive services coverage based on
recommendations from the U.S. Preventive Services Task Force and the Institute of Medicine. These preventive
medications are covered under the Patient Protection and Affordable Care Act at no cost ($0 copayment) to Members
when prescribed by a licensed provider and filled at a network pharmacy. Coverage limitations such as age and gender
rules apply, see Special Coverage Considerations for details below. This coverage does not apply to members of
“grandfathered” plans.
Note: Preventive over-the-counter (OTC) medications are covered in full when prescribed by a licensed Provider and
dispensed at a pharmacy pursuant to a prescription.
Medication
Aspirin ≤ 325 mg
Applies To
OTC Generic Only
Fluoride drops & tablets
Rx Brands and Generics
Folic acid 0.4 mg, 0.8 mg, 1mg
Iron liquid supplements
Preventive medications for the risk
reduction of primary breast cancer in
women: Evista, Soltamox, Raloxifene
and Tamoxifen
Prescription smoking cessation
products
Revised 06/09/14
OTC and Rx Generic
Only
OTC Brands and
Generics
Special Coverage Considerations
Covered in full for Members age 45 years and older
Covered in full for preschool children age 6 months
through age 6
Covered in full for women of childbearing age (12 –
52 years)
Covered in full for children up to 12 months of age
Rx Brands and Generics
Covered in full for women
Rx Brands and Generics
Covered in full. Quantity limitations may apply.
19
Preventive Services
Medication
Vitamin D 400 unit capsules, drops
and tablets; 400 unit/ mL oral liquid;
1,000 unit/ 10 mL oral liquid; 1,200
unit/ 15 mL oral liquid
Applies To
Special Coverage Considerations
OTC Brands and
Generics
Covered in full for Members age 65 years and older
FDA-Approved Over-the-Counter (OTC) Contraceptives for Women
These preventive medications are covered under the Patient Protection and Affordable Care Act at no cost ($0
copayment) to female Members when prescribed by a licensed Provider and dispensed at a network pharmacy pursuant
to a prescription. This coverage does not apply to members of “grandfathered” plans, and certain religious group
employers are exempt from the requirement to cover contraceptive services.
Contraceptive films
Contraceptive foams
Contraceptive gels
Emergency contraceptives
Female condoms
Prescription Contraceptives for Women
Contraceptives, including oral contraceptives, diaphragms, and other self-administered hormonal contraceptives (e.g.,
patches, rings) that by law require a prescription are covered in full for women under the Pharmacy Benefit ($0
copayment).
Contraceptives that are administered by a health care professional, including cervical caps, IUDs and implantable
contraceptives that by law require a prescription are covered in full for women under the Medical Benefit. For additional
information, see the Women’s Health section of this Preventive Services Payment Policy.
This coverage does not apply to members of “grandfathered” plans, and certain religious group employers are exempt
from the requirement to cover contraceptive services.
Note: Male contraceptives are not covered under the Patient Protection and Affordable Care Act.
WOMEN’S HEALTH
Beginning August 1, 2012, and effective on the member’s plan renewal date, Tufts Health Plan will cover the women’s
preventive health care services as indicated in this section, with no cost share for most members when those services are
rendered by a provider in the member’s plan network.
Outpatient Maternity Services
Beginning January 1, 2014, for new groups and upon plan renewal date for existing members of all fully and self-insured
non-grandfathered plans all outpatient routine prenatal and postpartum office visits will be covered in full. Any
outpatient maternity services not considered routine or those related to complications or risks with a pregnancy, may be
subject to cost sharing based on the member’s plan. Some examples of services not considered routine include, but are
not limited to, amniocentesis, fetal stress testing, and OB ultrasounds.
Note: This does not include inpatient maternity services which may be subject to cost share based on member’s plan
design.
The below CPT codes are considered routine:
CPT Code
Description
Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or
59400
forceps) and postpartum care
Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care
59410
59425
Antepartum care only; 4-6 visits
59426
Antepartum care only; 7 or more visits
59430
Postpartum care only (separate procedure)
59510
Routine obstetric care including antepartum care, cesarean delivery, and postpartum care
59515
Cesarean delivery only; including postpartum care
Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or
59610
forceps) and postpartum care, after previous cesarean delivery
Revised 06/09/14
20
Preventive Services
CPT Code
59614
59618
59622
Description
Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps);
including postpartum care
Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following
attempted vaginal delivery after previous cesarean delivery
Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery; including
postpartum care
Breastfeeding support, supplies and counseling for pregnant and postpartum Women
The below HCPCS codes are considered preventive:
CPT Code
Description
A4281
Tubing for breast pump, replacement
A4282
Adapter for breast pump, replacement
A4283
Cap for breast pump bottle, replacement
A4284
Breast shield and splash protector for use with breast pump, replacement
A4285
Polycarbonate bottle for use with breast pump, replacement
A4286
Locking ring for breast pump, replacement
E0602
Breast pump, manual, any type
E0603
Breast pump, electric (AC and/or DC), any type
E0604
Breast pump, hospital grade, electric (AC and/or DC), any type
S9443
Lactation classes, nonphysician provider, per session
Contraception and Contraceptive Counseling
FDA-approved over-the-counter female contraceptives are considered preventive when prescribed by a licensed
provider and dispensed at a pharmacy pursuant to a prescription.
Emergency contraceptives, including Ella® and generics of Plan B® and Plan B One-Step® are considered preventive.
The below CPT codes are considered preventive when billed with one of the following - ICD-9 code V25.2 (Sterilization)
or ICD-10 code Z30.2 (Encounter for sterilization):
CPT Code
Description
00952
Anesthesia for vaginal procedures; hysteroscopy and/or hysterosalpingography
58555
Hysteroscopy, diagnostic
Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of
58565
permanent implants
58600
Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral
Ligation or transection of fallopian tube(s), abdominal or vaginal approach, postpartum, unilateral or
58605
bilateral, during same hospitalization
Ligation or transection of fallopian tube(s) when done at the time of cesarean delivery or intra58611
abdominal surgery (not a separate procedure)
58615
Occlusion of fallopian tube(s) by device (e.g., band, clip, Falope ring) vaginal or suprapubic approach
58670
Laparoscopy, surgical; with fulguration of oviducts (with or without transection)
58671
Laparoscopy, surgical; with occlusion of oviducts by device (e.g., band, clip, or Falope ring)
Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; tubal
00851
ligation/transection
Level II - Surgical pathology, gross and microscopic examination Appendix, incidental, Fallopian tube,
88302
sterilization
99144*
Moderate sedation age 5 years or older, first 30 minutes intra-service time
99145*
Moderate sedation each additional 15 minutes intra-service time
A4264
Permanent implantable contraceptive intratubal occlusion device(s) and delivery system
*Considered preventive when billed with CPT code 58555 or 00952.
Revised 06/09/14
21
Preventive Services
The below CPT/HCPCS codes are considered preventive when billed with one of the below ICD-9 codes or ICD-10 codes:
CPT Code
Description
11976
Removal, Implantable contraceptive capsules
Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets
11980
beneath the skin)
11981
Insertion, non-biodegradable drug delivery implant
11982
Removal, non-biodegradable drug delivery implant
11983
Removal with reinsertion, non-biodegradable drug delivery implant
57170
Diaphragm & cervical cap fitting
58300
Insertion of IUD
58301
Removal of IUD
Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or
96372
intramuscular
Office or other outpatient visit for the evaluation and management of an established patient, that may
99211
not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5
minutes are spent performing or supervising these services.
A4261
Cervical cap for contraceptive use
A42661
Diaphragm for contraceptive use
1
A4268
Contraceptive supply, condom, female, each
A42691
Contraceptive supply, spermicide (e.g., foam, gel), each
J1050
Injection, medroxyprogesterone acetate, 1 mg (Depo-Provera)
J7300
Intrauterine Copper Contraceptive
J7301
Levonorgestrel-releasing intrauterine contraceptive system (Skyla), 13.5 mg
J7302
Levonorgestrel 52 mg intrauterine device releases levonorgestrel 20 mcg/day (Mirena)
J73031
Contraceptive supply, hormone containing vaginal ring, each
1
J7304
Contraceptive supply, hormone containing patch, each
J7307
Etonogestrel (contraceptive) implant system, including implant and supplies
S4989
Contraceptive intrauterine device (e.g., Progestacert IUD, including implants and supplies)
S4993
Contraceptive pills for birth control
ICD-9 Diagnosis Code
V25.02
V25.11 - V25.13
V25.40 – V25.43
V25.9
V45.51
V45.52
Description
Initiation of other contraceptive measures
Encounter for insertion or removal of intrauterine contraceptive device
Surveillance of previously prescribed contraceptive methods
Unspecified contraceptive management
Intrauterine contraceptive device
Subdermal contraceptive implant
The following ICD-10 codes are effective for dates of service on or after October 1, 2015:
ICD-10 Diagnosis Code
Description
Z30.013 – Z30.019
Encounter for initial prescription of contraceptives
Z30.4 – Z30.9
Encounter for surveillance of contraceptives or Encounter for contraceptive management
Z97.5
Presence of (intrauterine) contraceptive device
Domestic Violence
Screening for domestic violence covered as part of the annual well-woman visit.
Gestational Diabetes
The below CPT codes are considered preventive when billed with one of the below ICD-9 or ICD-10 codes:
CPT Code
Description
80422
Glucagon tolerance panel; for insulinoma
1
Covered under the Pharmacy benefit.
Revised 06/09/14
22
Preventive Services
CPT Code
82950
82951
82952
ICD-9 Diagnosis Code
V22.0
V22.1
V22.2
V23.0
V23.1
V23.2
V23.3
V23.41
V23.49
V23.5
V23.7
V23.81
V23.82
V23.83
V23.84
V23.85
V23.86
V23.89
V23.9
Description
Glucose; post glucose dose (includes glucose)
Glucose; tolerance test (GTT), 3 specimens (includes glucose)
Glucose; tolerance test, each additional beyond 3 specimens (List separately in addition to
code for primary procedure)
Description
Supervision of normal pregnancy
Supervision of other than normal pregnancy
Pregnant state, incidental
Pregnancy with history of infertility
Pregnancy with history of trophoblastic disease
Pregnancy with history of abortion
Grand multiparity
Pregnancy with history of labor pre-term
Pregnancy with other poor obstetric history
Pregnancy with other poor reproductive history
Insufficient prenatal care
Elderly primigravida
Elderly multigravida
Young primigravida
Young multigravida
Pregnancy resulting from assisted reproductive technology
Pregnancy with history of in-utero procedure during previous pregnancy
Other high-risk pregnancy
Unspecified high-risk pregnancy
The following ICD-10 codes are effective for dates of service on or after October 1, 2015:
ICD-10 Diagnosis Code
Description
O09.00 - O09.93
Supervision of high risk pregnancy
Z33.1
Pregnant state, incidental
Z34.00 - Z34.93
Encounter for supervision of normal pregnancy
HIV Screening and Counseling
Please refer to the HIV: Adults and Adolescents and Pregnant Women section of this document.
HPV DNA Testing for Women ages 30 or older
The below CPT codes are considered preventive:
CPT Code
Description
87620
Infectious agent detection by nucleic acid (DNA or RNA)
Infectious agent detection by nucleic acid (DNA or RNA); papillomavirus, human, amplified
87621
probe technique
Infectious agent detection by nucleic acid (DNA or RNA); papillomavirus, human,
87623
quantification
Sexually Transmitted Infections (STI) Screening and Counseling
Please refer to the STI Screening and STI counseling sections of this document.
Well-Woman Visit
Please refer to the preventive office visit section of this document.
COMPENSATION/REIMBURSEMENT INFORMATION
Providers are compensated according to the Tufts Health Plan network contracted rates regardless of the address where
the service is rendered. Claims are subject to payment edits that are updated at regular intervals and generally based on
CMS, specialty society guidelines, drug manufacturers’ package label inserts, and National Correct Coding Initiative (CCI).
Revised 06/09/14
23
Preventive Services
DOCUMENT HISTORY
 July 3, 2013: Added CPT codes 99460, 99461, 99462, 99463, 58555, 99144, 99145 and Removed CPT code Q0090.
 August 7, 2013: Added CPT code 90664.
 September 25, 2013: Updated language. Added HCPCS codes A4268, A4269 and Removed HCPCS code J8499.
 October 24, 2013: Formatting changes. Added CPT Code 90661.
 November 5, 2013: Removed CPT code 77079.
 December 30, 2013: Formatting changes. Added CPT/HCPCS code(s) 90673, J7301, S0195 and Removed HCPCS code
Q2033.
 January 7, 2014: Formatting changes.
 January 23, 2014: Formatting changes.
 March 10, 2014: Added new recommendation section(s) “BRCA Genetic Counseling” “BRCA Genetic Testing” and
“Lung Cancer Screening”.
 March 12, 2014: Formatting changes.
 April 11, 2014: Added “Raloxifene” to Pharmacy Section. Removed diagnosis component requirement from
Immunization section.
 May 30, 2014: Formatting changes. Added CPT code 84478.
 June 9, 2014: Formatting changes. Added CPT code 82465. Clarified coding for “Gestational Diabetes Screening” and
“Type 2 Diabetes Mellitus”. Added diagnosis component to “Venipuncture” section.
Revised 06/09/14
24
Preventive Services