WIXLIB

brief familial risk assessment tool.Women with a positive result on therisk assessment tool should receivegenetic counseling and, if indicatedafter counseling, genetic testing.Procedure Code(s):BRCA Lab Screening81162, 81163, 81164, 81165, 81166, 81167,81212, 81215, 81216, 81217Blood Draw:36415, 36416Diagnosis Code(s):Family History or Personal History of breastcancer and/or ovarian cancer:Z15.01, Z15.02, Z80.3, Z80.41, Z85.3, Z85.43Pre-Diabetes and Type 2 DiabetesScreeningUSPSTF Rating (August 2021): BThe USPSTF recommends screeningfor prediabetes and type 2 diabetes inadults aged 35 to 70 years who haveoverweight or obesity. Cliniciansshould offer or refer patients withprediabetes to effective preventiveinterventions.Refer also to the BehavioralCounseling section in Primary Care toPromote a Healthful Diet and PhysicalActivity for Cardiovascular DiseasePrevention in Adults withCardiovascular Risk Factors forintensive behavioral counselinginterventions.For additional diabetes screeningbenefits, refer also to the ExpandedWomen’s Preventive Health sectionfor Screening for GestationalDiabetes Mellitus and Screening forDiabetes Mellitus After Pregnancy.For additional coverage on diabetesprevention program preventivebenefits refer to the DiabetesPrevention Program section.Procedure Code(s):Diabetes Screening:82947, 82948, 82950, 82951, 82952, 83036Blood Draw:36415, 36416Diagnosis Code(s):Required Diagnosis Codes (requires at leastone):Z00.00, Z00.01, Z13.1AND One of the following additional diagnosiscodes as follows: (requires at least one):Overweight: E66.3, Z68.25, Z68.26, Z68.27,Z68.28, Z68.29Obesity : E66.01, E66.09, E66.1, E66.8, E66.9,Z68.41, Z68.42, Z68.43, Z68.44, Z68.45Body Mass Index 30.0 – 39.9:Z68.30, Z68.31, Z68.32, Z68.33, Z68.34, Z68.35,Z68.36, Z68.37, Z68.38, Z68.39Body Mass Index 40.0 and Over:Z68.41, Z68.42, Z68.43, Z68.44, Z68.45Pre-Diabetes Preventive InterventionsProcedure Code(s):Medical Nutrition Therapy or Counseling:97802, 97803, 97804, G0270, G0271, S9470Preventive Medicine Individual Counseling:99401, 99402, 99403, 99404Behavioral Counseling or Therapy:0403T, G0447, G0473Diagnosis Code(s):R73.03 (prediabetes)5Limited to one test per member,per lifetime.BRCA Lab Screening:Certification requirements applyto BRCA lab screening.Blood Draw:Requires one of the BRCA LabScreening procedure codeslisted in this row AND one of theBRCA Lab Screening diagnosiscodes listed in this row.Limited to age 35-70 years (endson 71st birthday).Diabetes Screening:Requires one of the RequiredDiagnosis Codes listed in thisrow AND one of the listedAdditional Diagnosis Codes inthis row.Blood Draw:Requires ALL of the following:- One of the listed DiabetesScreening procedure codeslisted in this row AND- One of the listed RequiredDiagnosis Codes AND- One of the listed AdditionalDiagnosis Codes.Preventive Benefit Does NotApply:If a Diabetes Diagnosis Code ispresent in any position, thepreventive benefit does notapply; refer to the DiabetesDiagnosis Code List.Pre-Diabetes PreventiveInterventionsLimited to age 35-70 years (endson 71st birthday).Requires diagnosis code R73.03.

Gestational Diabetes MellitusScreeningUSPSTF Rating (Aug. 2021) B:The USPSTF recommends screeningfor gestational diabetes mellitus inasymptomatic pregnant persons at 24weeks of gestation or after.Refer to the expanded Women’s PreventiveHealth section for Screening for GestationalDiabetes Mellitus codes.Note: This benefit appliesregardless of the gestationalweek.For additional diabetes screeningbenefits, also see the DiabetesScreening row. Also see theExpanded Women’s PreventiveHealth section for Screening forGestational Diabetes Mellitus andScreening for Diabetes Mellitus AfterPregnancy.Screening MammographyUSPSTF Rating (2002): BThe USPSTF recommends screeningmammography, with or withoutclinical breast examination (CBE),every 1-2 years for women aged 40and older.Refer to the expanded Women’sPreventive Health section forScreening for GestationalDiabetes Mellitus preventivebenefit instructions.Procedure Code(s):77061, 77062, 77063, 77067Revenue Code:0403No age limits.Note: This benefit only applies toscreening mammography.Diagnosis Code(s):Does not have diagnosis code requirements forthe preventive benefit to apply.,Refer also to the Breast CancerScreening for Average-Risk Womenrecommendation in the ExpandedWomen’s Preventive Health section.Cervical Cancer ScreeningUSPSTF Rating (Aug. 2018): AThe USPSTF recommends screeningfor cervical cancer every 3 years withcervical cytology alone in womenaged 21 to 29 years.For women aged 30 to 65 years, theUSPSTF recommends: Screening every 3 years withcervical cytology alone, Every 5 years with high-risk humanpapillomavirus (hrHPV) testing alone,or Every 5 years with hrHPV testing incombination with cytology (cotesting).Bright Futures, March 2014:Adolescents should no longer beroutinely screened for cervicaldysplasia until age 21Procedure Code(s):Human Papillomavirus DNA Testing (HPV):0500T, 87624, 87625, G0476Diagnosis Code(s):Z00.00, Z00.01, Z01.411, Z01.419, Z11.51,Z12.4Limited to age 30 years and up.Cervical Cytology (Pap Test)Cervical Cytology (Pap Test)Code Group 1 Procedure Code(s):G0101, G0123, G0124, G0141, G0143, G0144,G0145, G0147, G0148, Q0091, P3000, P3001Code Group 1:Limited to age 21-65 years (endson 66th birthday).Does not have diagnosis coderequirements for preventivebenefits to apply.Code Group 1 Diagnosis Code(s):Does not have diagnosis code requirements forpreventive benefits to apply.Cervical Cytology (Pap Test)Cervical Cytology (Pap Test)Code Group 2 Procedure Code(s):88141, 88142, 88143, 88147, 88148, 88150,88152, 88153, 88155, 88164, 88165, 88166,88167, 88174, 88175Code Group 2:Limited to age 21-65 years (endson 66th birthday).Requires one of the Code Group2 diagnosis codes listed in thisrow.Code Group 2 Diagnosis Code(s):Z00.00, Z00.01, Z01.411, Z01.419, Z12.46Human Papillomavirus DNATesting (HPV):Requires one of the diagnosiscodes listed in this row.

Cholesterol Screening (LipidDisorders Screening)USPSTF Rating (Nov. 2016): BStatin Use for the Primary Preventionof Cardiovascular Disease in AdultsThe USPSTF recommends thatadults without a history ofcardiovascular disease (CVD) (i.e.,symptomatic coronary artery diseaseor ischemic stroke) use a low- tomoderate-dose statin for theprevention of CVD events andmortality when all of the followingcriteria are met:1. They are aged 40 to 75 years;2. They have 1 or more CVD riskfactors (i.e., dyslipidemia, diabetes,hypertension, or smoking); and3. They have a calculated 10-yearrisk of a cardiovascular event of 10%or greater.Procedure Code(s):Cholesterol Screening:80061, 82465, 83718, 83719, 83721, 83722,84478Blood Draw:36415, 36416Diagnosis Code(s):Z00.00, Z00.01, Z13.220USPSTF Rating (May 2021): AThe USPSTF recommends screeningfor colorectal cancer in all adults aged50 to 75 years.Fecal Occult Blood Resting (FOBT), FecalImmunochemical Test (FIT), Fecal DNA,Sigmoidoscopy, or ColonoscopyBlood Draw:Ages 40-75 years (ends on 76thbirthday): Requires one of thelisted Cholesterol Screeningprocedure codes AND one of theDiagnosis Codes listed in thisrow.Age Limits for ColorectalCancer Screenings:Ages 45 to 75 years (ends on76th birthday).Sigmoidoscopy, Colonoscopyand Fecal DNA preventivebenefits are limited to one everythree calendar years.USPSTF Rating (May 2021): BThe USPSTF recommends screeningfor colorectal cancer in adults aged45 to 49 years.Code Group 1:Sigmoidoscopy: G0104, G0106Colonoscopy: G0105, G0120, G0121, G0122FOBT and FIT: G0328Colonoscopy Pre-Op Consultation: S0285Code Group 1 Diagnosis Code(s):Does not have diagnosis code requirements forpreventive benefits to apply.7Requires one of the diagnosiscodes listed in this row.Preventive Benefit Does NotApply:For all ages above, if any of thefollowing lipid disordersdiagnosis codes are present inany position, the preventivebenefit does not apply:E71.30, E75.5, E78.00, E78.01,E78.2, E78.3, E78.41, E78.49,E78.5, E78.79, E78.81, E78.89,E88.2, E88.89Identification of dyslipidemia andcalculation of 10-year CVD event riskrequires universal lipids screening inadults aged 40 to 75 years.Notes: For statin medications benefits, referto the pharmacy plan administrator. For recommendations for children,refer to Dyslipidemia Screening(Bright Futures).Colorectal Cancer ScreeningCholesterol Screening:Age 40-75 years (ends on 76thbirthday).FOB/FIT preventive benefit islimited to one test per calendaryear.Code Group 1:Does not have diagnosis coderequirements for preventivebenefits to apply.

Code Group 2:Sigmoidoscopy: 45330, 45331, 45333, 45338,45346Colonoscopy: 44388, 44389, 44392, 44394,45378, 45380, 45381, 45384, 45385, 45388FOBT and FIT: 82270, 82274Code Group 2 Diagnosis Code(s):Z00.00, Z00.01, Z12.10, Z12.11, Z12.12, Z80.0,Z83.71, Z83.79Code Group 3:Pathology:88304, 88305Code Group 4:Anesthesia:00812, 99152, 99153, 99156, 99157, G0500Code Group 2:Requires one of the diagnosiscodes listed for this group ORone of the procedure codes fromCode Group 1, regardless ofdiagnosis.Code Group 3 (Pathology)AND Code Group 4(Anesthesia):Requires one of the diagnosiscodes listed for this group ANDone of the procedure codes fromCode Group 1 or Code Group 2.Code Group 3 & 4 Diagnosis Code(s):Z00.00, Z00.01, Z12.10, Z12.11, Z12.12, Z80.0,Z83.71, Z83.79Code Group 3 and 4:Note: Preventive whenperformed for a colorectal cancerscreening. Preventive benefitsonly apply when the surgeon’sclaim is preventive.Code Group 5:Pre-op/Consultation:99202, 99203, 99204, 99205, 99211, 99212,99213, 99214, 99215, 99241, 99242, 99243,99244, 99245, 99417Code Group 5:Requires one of the Code Group5 diagnosis codes.Diagnosis Code Group 5:Z12.10, Z12.11, Z12.12. Z80.0, Z83.71, Z83.79Code Group 6:Fecal DNA:81528Code Group 6 Diagnosis Code(s):Does not have diagnosis code requirements forpreventive benefits to apply.8Code Group 6 (Fecal DNA):Does not have diagnosis coderequirements for preventivebenefits to apply.

Wellness Examinations(well baby, well child, well adult)USPSTF Rating: NoneHealthChoice supports AAP andAAFP age and frequency guidelines,as well as recommendations of BrightFutures.HRSA Requirements:The Wellness Examinations codesinclude the following HRSArequirements for Women: Breastfeeding support andcounseling Contraceptive methods counselingand follow-up care Domestic violence screening Annual HIV counseling Sexually transmitted infectionscounseling Well-woman visits Screening for urinary incontinenceProcedure Code(s):Preventive medicine services (evaluation andmanagement):99381, 99382, 99383, 99384, 99385, 99386,99387, 99391, 99392, 99393, 99394, 99395,99396, 99397Medicare wellness exams:G0402, G0438, G0439STIs behavioral counseling:G0445Annual gynecological exams:S0610, S0612, S0613Preventive medicine, individual counseling:99401, 99402, 99403, 99404Preventive medicine, group counseling:99411, 99412Does not have diagnosis coderequirements for the preventivebenefit to apply.Limited to two annual wellnessexams per calendar year forages 18 and older.For ages 17 and younger,wellness visit frequency isdetermined in accordance withBright Futures recommendations.STI Behavioral Counseling:G0445 is limited to twice percalendar year.LDCT: G0296 is limited to age 50to 80 years (ends on 81stbirthday) and is limited to onceper calendar year.Newborn Care (evaluation and management):99461Counseling Visit (to discuss the need for LungCancer Screening (LDCT) using Low Dose CTScan):G0296Diagnosis Code(s):Does not have diagnosis code requirements forthe preventive benefit to apply.Vaccines (Immunizations)USPSTF Rating: NoneAn Immunization that does not fallunder one of the exclusions in theCertificate of Coverage is consideredcovered after the following conditionsare satisfied:1. FDA approval;2. Explicit ACIP recommendationsfor routine use published in theMorbidity & Mortality Weekly Report(MMWR) of the Centers for DiseaseControl and Prevention (CDC).Implementation will typically occurwithin 60 days after publication in theMMWR.9Refer also to the Expanded Women’s PreventiveHealth section.Refer to the Preventive Vaccines(Immunizations) section.Refer to the Preventive Vaccines(Immunizations) section

Newborn ScreeningsAll newbornsUSPSTF Rating (March 2008): AHypothyroidism Screening: Screeningfor congenital hypothyroidism innewborns.USPSTF Rating (March 2008): APhenylketonuria Screening:Screening for phenylketonuria (PKU)in newborns.USPSTF Rating (Sept. 2007): ASickle Cell Screening: Screening forsickle cell disease in newborns.Note: For Bright Futures hearingscreening, refer to the HearingScreening/Tests (Bright Futures).Metabolic Screening Panel(Newborns)Procedure Code(s):Hypothyroidism Screening:84437, 84443Blood Draw:36415, 36416Phenylketonuria Screening:84030, S3620Blood Draws:36415, 36416Sickle Cell Screening:83020, 83021, 83030, 83033, 83051, S3850Blood Draws:36415, 36416USPSTF Rating (June 2018): BWomen 65 and older: The USPSTFrecommends screening forosteoporosis with bone measurementtesting to prevent osteoporoticfractures in women 65 years andolder.USPSTF Rating (June 2018): BPostmenopausal women youngerthan 65 years at increased risk ofosteoporosis: The USPSTFrecommends screening forosteoporosis with bone measurementtesting to prevent osteoporoticfractures in postmenopausal womenyounger than 65 years who are atincreased risk of osteoporosis, asdetermined by a formal clinical riskassessment tool.10Blood Draw:Age 0-90 days, requires one ofthe listed HypothyroidismScreening, PhenylketonuriaScreening, or Sickle CellScreening procedure codes.Diagnosis Code(s):Does not have diagnosis code requirements forthe preventive benefit to apply.Procedure Code(s):Metabolic Screening Panel:82017, 82136, 82261, 82775, 83020, 83498,83516, 84030, 84437, 84443, S3620Metabolic Screening Panel:Age 0-90 days. Does not havediagnosis code requirements forthe preventive benefit to apply.Blood Draw:36415, 36416Blood Draw:Age 0-90 days. Requires one ofthe listed Metabolic ScreeningPanel procedure codes listed inthis row.Diagnosis Code(s):Does not have diagnosis code requirements forthe preventive benefit to apply.Osteoporosis ScreeningNewborn Screenings:Does not have diagnosis coderequirements for the preventivebenefit to apply.Procedure Code(s):76977, 77080, 77081, G0130Diagnosis Code(s):Z00.00, Z00.01, Z13.820, Z82.62Requires one of the diagnosiscodes listed in this row.

Screening and BehavioralCounseling Interventions inPrimary Care to Reduce UnhealthyAlcohol Use in AdultsUSPSTF Rating (Nov. 2018): BThe USPSTF recommends screeningfor unhealthy alcohol use in primarycare settings in adults 18 years orolder, including pregnant women, andproviding persons engaged in risky orhazardous drinking with briefbehavioral counseling interventions toreduce unhealthy alcohol use.Procedure Code(s):Alcohol or Drug Use Screening:99408, 99409, H0049Annual Alcohol Screening:G0442Brief Counseling for Alcohol:G0443Limited to age 18 and older.Limited to two screenings percalendar year.Does not have diagnosis coderequirements for preventivebenefits to apply.Diagnosis Code(s):Does not have diagnosis code requirements forpreventive benefit to apply.Bright Futures (April 2017):Bright Futures recommends alcoholor drug use assessments from age11-21 years.Also see rows: Unhealthy Drug UseScreening (Adults); and Tobacco,Alcohol, or Drug Use Assessment(Bright Futures).High Blood Pressure in Adults –Screening:Blood Pressure Measurement in a ClinicalSetting:USPSTF Rating (April 2021): AThe USPSTF recommends screeningfor hypertension in adults 18 years orolder with office blood pressuremeasurement.N/AThe USPSTF recommends obtainingmeasurements outside of the clinicalsetting for diagnostic confirmationbefore starting treatment.Breast Cancer: Medications forRisk ReductionUSPSTF Rating (Sept. 2019): BThe USPSTF recommends thatclinicians offer to prescribe riskreducing medications, such astamoxifen, raloxifene, or aromataseinhibitors, to women who are atincreased risk for breast cancer andat low risk for adverse medicationeffects.11Ambulatory Blood Pressure Measurement(Outside of a Clinical Setting):Ambulatory Blood Pressure Measurement:93784, 93786, 93788, 93790Diagnosis Code(s):Abnormal Blood-Pressure Reading WithoutDiagnosis of Hypertension:R03.0N/ABlood Pressure Measurementin a Clinical Setting:This service is included in apreventive care wellnessexamination.Ambulatory Blood PressureMeasurement (Outside of aClinical Setting):Age 18 years and up. Requiresthe diagnosis code listed in thisrow.This service is included in apreventive care wellnessexamination or focused E&Mvisit. Refer to pharmacy benefitsfor additional coverage.

Prostate Cancer Screening: MenUSPSTF Rating for Men 55 - 69 (May2018): CUSPSTF Rating for Men 70 an Over(May 2018): DThe USPSTF For men aged 55 to 69years, the decision to undergoperiodic prostate-specific antigen(PSA)–based screening for prostatecancer should be an individual one.Before deciding whether to bescreened, men should have anopportunity to discuss the potentialbenefits and harms of screening withtheir clinician and to incorporate theirvalues and preferences in thedecision. Screening offers a smallpotential benefit of reducing thechance of death from prostate cancerin some men. However, many menwill experience potential harms ofscreening, including false-positiveresults that require additional testingand possible prostate biopsy; overdiagnosis and overtreatment; andtreatment complications, such asincontinence and erectile dysfunction.In determining whether this service isappropriate in individual cases,patients and clinicians shouldconsider the balance of benefits andharms on the basis of family history,race/ethnicity, comorbid medicalconditions, patient values about thebenefits and harms of screening andtreatment-specific outcomes, andother health needs. Clinicians shouldnot screen men who do not express apreference for screening.Procedure Code(s):84152, 84153, 84154, G0102, G0103Limited to males age 40 andover.Diagnosis Code(s):Does not have diagnosis code requirements forpreventive benefit to apply.Limit of one per calendar year.Metabolic Screening P

HealthChoice covers qualifying preventive care services at 100% of allowable amounts when rendered by a participating network provider. Qualifying coverage may be determined by age, gender or other factors. There could be certain codes not payable in all circumstances due to other polices or guidelines, including coverage limitations or