Preventive Health Benefits and Coding - BCBSND
Preventive Health Benefits and Coding
The Preventive Health Benefits and Coding Guidelines (Guidelines) provide additional information related to specific types of preventive services, as defined under the Patient Protection and Affordable Care Act, which may be covered under a Member's Benefit Plan depending on factors such as grandfathered status, product type and anniversary date, and contraception exemptions. The terms and conditions of the written Benefit Plan govern the benefits available to Members, and the Guidelines do not guarantee coverage or payment for a particular service. Members should contact Member Services at the telephone number and address on the back of their Identification Card for further preventive services information.
Preventive care services are for patients without recognized signs or symptoms of the target condition. Screening is the testing for disease in seemingly well individuals so that early detection and treatment can be provided for those who test positive for the disease.
If a screening service results in a diagnosis of a condition, the patient will be followed by a surveillance regimen and recommendations for screening are no longer applicable.
The testing of a person to rule out or confirm a suspected diagnosis because the patient has some sign or symptom is a diagnostic examination, not a screening.
Providers and members should reference the preauthorization list as some of the below services may require prior authorization to support medical necessity.
Guidelines
Preventive Service Immunizations
Description
Immunizations recommended by the Centers for Disease Control and prevention for age, and sex/gender vaccines.
CPT?/HCPCS Code Diagnosis Code - ICD 10 See CPT? for appropriate vaccine and administration codes.
Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross Blue Shield Association
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Preventive Service Infants and Children Pediatric Preventive Visits ? 11 visits from birth
through 35 months ? Annual visit after
36 months
Cholesterol Screening ? 1 every 5 years
Developmental/Autism Screening ? through age 2
Hearing Screening ? per calendar year
through age 21
Description Includes an age and gender appropriate history; physical examination; counseling, anticipatory guidance, or risk factor reduction interventions; and the ordering of laboratory or diagnostic procedures.
Screening test for high cholesterol if determined to be at high risk.
Screening to determine if the patient needs additional work-upfor a developmental disorder. Requires use of a Standardized, validated tool.
Requires use of calibrated electronic equipment; tests using other methods (e.g., whispered voice, tuning fork) are not reported separately.
CPT?/HCPCS Code Diagnosis Code - ICD 10
99381 99382 99383 99384 99385 99386 99387 99391 99392 99393 99394 99395 99396 99397 S0610 S0612 S0613 G0101 99202 99203 99204 99205 99211 99212 99213 99214 99215 80061 82465 83718 84478
96110
92551 92552 92558 92567 92587 92588 92650 92651 V5008
Diagnosis code requirements are not applicable.
Z00.110 Z00.111 Z00.121 Z00.129 Z00.3 Z01.411 Z01.419
Z00.00 Z00.01 Z00.121 Z00.129 Z13.220 Z00.110 Z00.111 Z00.121 Z00.129 Z13.40 Z13.41 Z13.42 Z13.49 Z00.00 Z00.01 Z00.110 Z00.111 Z00.121 Z00.129 Z00.3 Z01.10 Z01.118
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Preventive Service
Description
CPT?/HCPCS Code Diagnosis Code - ICD 10
Infants and Children (Continued)
Lead Screening
For children at risk for
83655
Diagnosis code
? through age 6
lead exposure.
requirements are
not applicable.
Oral Health
Oral health screenings by a
Assessment Included in Well Child Care
primary care provider and
preventive visit.
referral to a dentist at the
appropriate age.
Prevention of Dental Primary care clinicians
99188
Diagnosis code
Caries in Children
may prescribe oral fluoride
D1206
requirements
? through age 6
supplementation starting at
are not applicable.
age 6 months through age
16 for children whose water
supply is deficient in fluoride.
Over-the-counter fluoride
tablets will be non-covered.
Primary Care clinicians apply
fluoride varnish to the primary
teeth of all infants and children
starting at the age of primary
tooth eruption through age
6. Prescription required for
oral fluoride supplementation.
Handled through the pharmacy
benefit manager.
Tuberculin Test
Screening test for tuberculosis if 86480
Z00.00
determined to be at high-risk. 86481
Z00.01
86580
Z00.121
Z00.129
Z11.1
Z11.7
Vision Screening
Graduated visual acuity stimuli 99173
Z00.00
? per calendar year that allow a quantitative
99174
Z00.01
through age 21
estimate of visual acuity
99177
Z00.110
(e.g., Snellen chart). Does
Z00.121
not include refractions.
Z00.129
Z00.111
Newborn Screenings
Congenital
Federally mandated newborn 84436
Z00.110
Hypothyroidism
test. Generally provided prior 84437
Z00.111
? through age 1
to newborn discharge.
84439
Z00.121
84443
Z00.129
Z13.29
Gonorrhea, Prophylactic Generally provided prior
Included in Newborn Hospital Claim
Eye Medication
to newborn discharge.
Iron Deficiency Anemia ? through age 2
Federally mandated newborn test. Generally provided prior to newborn discharge.
85013 85014 85018
Z00.110 Z00.111 Z00.121 Z00.129 Z13.0
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Preventive Service
Description
CPT?/HCPCS Code Diagnosis Code - ICD 10
Newborn Screenings (Continued)
Newborn Blood/PKU
Federally mandated newborn S3620
Z00.110
? through age 1
test. Generally provided prior
Z00.111
to newborn discharge.
Z00.121
Z00.129
Z13.228
Sickle Cell Anemia
Federally mandated newborn 83020
Z00.110
? through age 1
test. Generally provided prior 83021
Z00.111
to newborn discharge.
83030
Z00.121
83033
Z00.129
83051
Z13.0
S3850
Adult/Adolescent Preventive Services
Annual Visit
Includes an age and gender 99381 99393 Diagnosis code
? 2 visits for Females appropriate history; physical 99382 99394 requirements are
? 1 visit for Males
examination; counseling,
99383 99395 not applicable.
anticipatory guidance, or risk 99384 99396
factor reduction interventions; 99385 99397
and the ordering of laboratory 99386 S0610
or diagnostic procedures.
99387 S0612
99391 S0613
99392 G0101
99202
Z00.00
99203
Z00.01
99204
Z00.110
99205
Z00.111
99211
Z00.121
99212
Z00.129
99213
Z00.3
99214
Z01.411
99215
Z01.419
Alcohol and Drug
Annual Screening in primary 99408
Diagnosis code
Use Assessment
care settings can identify
99409
requirements are
? greater than age 5 patients whose levels
G0396
not applicable.
or patterns of alcohol
G0397
consumption place them at risk G0442
for increased morbidity and G0443
mortality and provide persons G2011
engaged in risky or hazardous
drinking with brief behavioral
counseling interventions to
reduce alcohol misuse.
Aspirin 81 mg
Use of aspirin for men
Prescription required. Handled through the
? when prescribed
ages 45-79 or women
pharmacy benefit manager.
ages 55-79 when the potential
benefit of a reduction in
ischemic strokes outweighs the
potential harm of an increase
in gastrointestinal hemorrhage.
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Preventive Service
Description
CPT?/HCPCS Code Diagnosis Code - ICD 10
Adult/Adolescent Preventive Services (Continued)
Behavioral Counseling to Recommends offering or
99401
E66.01
Z68.36
Promote a Healthful Diet referring adults who are
99402
E66.09
Z68.37
and Physical Activity for overweight or obese and
99403
E66.1
Z68.38
Cardiovascular Disease have additional cardiovascular 99404
E66.2
Z68.39
Prevention in Adults
disease (CVD) risk factors to
99411
E66.8
Z68.41
with Cardiovascular
intensive behavioral counseling 99412
E66.9
Z68.42
Risk Factors
interventions to promote a
97802
Z68.30
Z68.43
? Licensed Registered healthful diet and physical
97803
Z68.31
Z68.44
Dietician visits are activity for CVD prevention.
97804
Z68.32
Z68.45
available up to
G0447
Z68.33
Z68.52
4 visits per year for
G0473
Z68.34
Z68.53
hyperlipidemia and
S9470
Z68.35
Z68.54
2 visits per year
for hypertension
Medications for the
Clinicians should engage in
Prescription required. Handled through the
Preexposure Prophylaxis informed decision making
pharmacy benefit manager.
(PrEP) for Prevention with persons at high risk of
of Human
Human Immunodeficiency
Immunodeficiency
Virus (HIV) acquisition about
Virus (HIV) Infection
medications to reduce their
? For persons at high risk. For persons who are at
risk of HIV acquisition high risk of acquiring HIV,
clinicians may offer to prescribe
recommended riskreducing
antiretroviral medications,
such as Truvada.
Screening and
Screening and counseling
99401
Z00.00
Counseling for
involve elicitation of
99402
Z00.01
Interpersonal and
information from men, women, 99403
Z00.121
Domestic Violence
non-binary individuals and
99404
Z00.129
? greater than 6 years adolescents about current
Z00.3
of age
and past violence and abuse
Z01.41
in a culturally sensitive and
Z01.419
supportive manner.
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