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Women's Preventive Services - CAM 094

Description 
The Federal Patient Protection and Preventive Care Act (PPACA) was passed by Congress and signed into law by the president in March 2010. The preventive services component of the law became effective Sept. 23, 2010. A component of the law was a requirement that all “non-grandfathered” health insurance plans are required to cover those preventive medicine services given an “A” or “B” recommendation by the U.S. Preventive Services Task Force (USPSTF).

Plans are not required to provide coverage for the preventive services if they are delivered by out-of-network providers.

Task Force recommendations are graded on a five-point scale (A – E), reflecting the strength of evidence in support of the intervention. Grade A: There is good evidence to support the recommendation that the condition be specifically considered in a periodic health examination. Grade B: There is fair evidence to support the recommendation that the condition be specifically considered in a periodic health examination. Grade C: There is insufficient evidence to recommend for or against the inclusion of the condition in a periodic health examination, but recommendations may be made on other grounds. Grade D: There is fair evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination. Grade E: There is good evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.

Those preventive medicine services listed as Grade A & B recommendations are covered without cost sharing (i.e., deductible, coinsurance or copayment) by health plans for appropriate preventive care services provided by an in-network provider. If the primary purpose for the office visit is for other than Grade A or B USPSTF preventive care services, deductible, coinsurance or copayment may be applied.

Services are typically included as part of a normal wellness visit; the appropriate office visit code should be used. Evaluation and Management codes for preventive services 99381 – 99397 will always be considered preventive. CPT codes 99401 – 99404, when used to designate a preventive service, must have the applicable wellness/preventive diagnosis code as the primary reason for the visit.

When the primary purpose of the service is the delivery of an evidence-based service in accordance with a U.S. Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’.

The correct coding as listed for both ICD-9 and CPT or HCPCS codes in this summary is also required along with Modifier 33. CPT Codes Copyright© 2011 American Medical Association.

Subject to change as regulations and further clarifications are received.

NOTE: THIS POLICY APPLIES ONLY TO NON-GRANDFATHERED PLANS.

Policy: 
BACTERIURIA, SCREENING IN PREGNANT WOMEN

USPSTF Recommendation
The USPSTF recommends screening for asymptomatic bacteriuria with urine culture for pregnant women at 12 to 16 weeks gestation or at the first prenatal visit, if later. (Grade A)
 
CPT Code:
CPT 87086
 
ICD-9 Codes:
V22.0 – V22.2 — Prenatal Visits
V23.0 – V23.9 — Prenatal visits for patients with high risk pregnancies
 
ICD-10 Codes:
Z331
Z34 – Z3493
O0900 – O0933 
 
BRCA TESTING, RISK ASSESSMENT GENETIC COUNSELING/TESTING
USPSTF RECOMMENDATION
The USPSTF recommends that (Grade B) 1)primary care providers screen women who have family members with breast, ovarian, tubal or peritoneal cancer with one of several screening tools designed to identify if family history may be associated with an increased risk for potentially harmful mutations in breast cancer susceptibility genes (BRCA1 or BRCA2). 2) Women with positive screening results should receive genetic counseling and 3) if indicated after counseling, BRCA testing. Examples of screening tools include, but are not limited to: Ontario Family Health Assessment tool, Manchester Scoring System, Referral Screening tool or the Pedigree Assessment tool.
 
CPT/HCPCS Codes:
CPT 99385 – 99387
CPT 99395 – 99397
CPT 81211 – 81217
CPT 81162
CPT 96040
HCPCS S0265
 
ICD-9 Codes:
V16.3 — Family history of breast cancer
V16.40 — Family history of malignant neoplasm, unspecified genital organ
V16.41 — Family history of ovarian cancer
V26.33 — Genetic counseling
 
ICD-10 Codes:
Z803
Z8049
Z8041
Z315
 
BREAST CANCER, PREVENTIVE MEDICATION
USPSTF Recommendation
The USPSTF recommends that clinicians engage in shared, informed decision making with women who are at increased risk for breast cancer about medications to reduce their risk. For women who are at increased risk for breast cancer and at low risk for adverse medication effects, clinicians should offer to prescribe risk-reducing medications, such as tamoxifen or raloxifene. (Grade B) Examples of screening tools include, but are not limited to Ontario Family Health Assessment tool, Manchester Scoring System, Referral Screening tool or the Pedigree Assessment tool.
 
CPT Codes:
CPT 99401 – 99404
 
ICD-9 Codes:
V16.3
V84.01
 
ICD-10 Codes:
Z803
Z1501
 
BREAST CANCER, SCREENING (MAMMOGRAPHY)
USPSTF Recommendation
The USPSTF currently recommends biennial screening mammography for women with or without clinical breast examination every 1 – 2 years for women 40 years of age and older. (Grade B)
 
CPT/HCPCS Codes:
CPT 77052 (code deleted as of 1/1/2017)
CPT 77057 (code deleted as of 1/1/2017)
CPT 77067 (effective 1/1/2017)
HCPCS G0202
 
ICD-9 Codes:
V76.10 — Breast screening, unspecified
V76.11 — Screening mammogram for high-risk patient
V76.12 — Other screening mammogram
V76.19 — Other screening breast examination
 
ICD-10 Codes:
Z1239
Z1231
 
BREASTFEEDING, COUNSELING
USPSTF Recommendation
The USPSTF recommends interventions during pregnancy and after birth to promote and support breastfeeding. (Grade B)
 
CPT Codes:
CPT 99401
CPT 99402
 
ICD-9 Codes:
V22.0 – V24.2
V24.1 — Postpartum care and examination of lactating mothers.
 
ICD-10 Codes:
Z331
Z34 – Z3493
O0900 – O0993
Z390 – Z392
 
NOTE: CAM 046 also addresses breast pumps and indicates the following two breast pumps are allowable for members who qualify for no cost sharing: the Ameda Purely Yours electric pump and the Ameda One Hand Manual pump. 
 
CERVICAL CANCER, SCREENING
USPSTF Recommendation
The USPSTF recommends screening for cervical cancer in women ages 21 to 65 years with cytology (Pap smear) every 3 years OR for women ages 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years. (Grade A)
 
HRSA (Bright Futures) Recommendation
Bright Futures recommends screening for cervical dysplasia with Pap smear within 3 years of onset of sexual activity
 
CPT/HCPCS Codes:
CPT 87623 – 87625
CPT 88141 – 88153
CPT 88164 – 88167
CPT 88174 – 88175
CPT 0500T
HCPCS G0101
HCPCS G0123 – G0124
HCPCS G0144 – G0145
 
ICD-9 Codes:
V723 — gynecological exam
V72.31 — Routine gynecological examination
V72.32 — Encounter for Papanicolaou cervical smear to confirm findings of recent normal smear following initial abnormal smear
V73.81 — Special screening examination for Human papillomavirus (HPV)
V76.2 — Special screening for malignant neoplasm of the cervix
 
ICD-10 Codes:
Z01411
Z01419
Z0142
Z124
Z1151
 
CHLAMYDIA INFECTION, SCREENING IN WOMEN & ADOLESCENTS
USPSTF Recommendation
The USPSTF recommends screening for chlamydial infection for all sexually active non-pregnant young women aged 24 and younger and for older non-pregnant women who are at increased risk. (Grade A)
                                                                  AND
The USPSTF recommends screening for chlamydial infection for all pregnant women age 24 and younger and for older pregnant women who are at increased risk. (Grade B)
 
HRSA (Bright Futures) Recommendation
Screen sexually active adolescents for chlamydia using tests appropriate to the patient population and clinical setting.
 
CPT Codes:
CPT 87490
CPT 87491
 
ICD-9 Codes:
V73.88 — Special screening examination for other specified chlamydial diseases
V73.98 — Special screening examination for unspecified chlamydial disease
 
ICD-10 Code:
Z118
 
CONTRACEPTION:
Food and Drug Administration-approved contraceptive methods, sterilization procedures and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
 
NOTE: The procedure filed will be used to determine no cost share issues, not the diagnosis filed.
NOTE: For 96372 to be considered for no cost share, J1050 will need to be filed on the same date of service

NOTE: Effective 01012023 FDA approved digital web based applications for contraception ONLY will be considered medically necessary. As there is no coding specific to those applications, they will be represented by the following codes: A9291 V25.9 and Z30.9

NOTE: For all over the counter or self purchased contraceptives, the member will file the request for reimbursement including the receipt of their payment.

CPT and HCPCS codes associated with contraceptives and sterilization:
00851 Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy.
11976 Removal, implantable contraceptive capsules
11980 Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets beneath the skin)
11981 Insertion, non-biodegradable drug delivery implant (e.g., Implanon)
11982 Removal, non-biodegradable drug delivery implant
11983 Removal with reinsertion, non-biodegradable drug delivery implant
57170 Diaphragm or cervical cap fitting with instructions
58300 Insertion of intrauterine device (IUD)
58301 Removal of intrauterine device (IUD)
58340 CATHETERIZATION AND INTRODUCTION OF SALINE OR CONTRAST MATERIAL FOR SALINE INFUSION SONOHYSTEROGRAPHY (SIS) OR HYSTEROSALPINGOGRAPHY  
58565 Hysteroscopy, surgical, with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants
58600 Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral
58605 Ligation or transection of fallopian tube(s), abdominal or vaginal approach, postpartum, unilateral or bilateral, during same hospitalization
58611  Ligation or transection of fallopian tube(s) when done at time of cesarean or intra-abdominal surgery
58615 Occlusion of fallopian tube(s), by device (e.g., band, clip, Falope ring) vaginal or suprapubic approach
58661  Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy). If filed with diagnosis Z30.2 
58670  LAPAROSCOPY, SURGICAL; WITH FULGURATION OF OVIDUCTS (WITH OR WITHOUT TRANSECTION). If filed with diagnosis Z30.2. 
58671 Laparoscopy, surgical, with occlusion of oviducts by device (e.g., band, clip or Falope ring)
58700 ***SALPINGECTOMY, COMPLETE OR PARTIAL, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE)  
96372  Therapeutic, Prophylactic or Diagnostic injection (specify substance or drug); subcutaneous or intramuscular 
A4261 Cervical cap for contraceptive use
A4264   Permanent implantable contraceptive intratubal occlusion device(s) and delivery system 
A4266 DIAPHRAGM FOR CONTRACEPTIVE USE
A4267 Contraceptive supply, condom, male, each to the grid of contraceptives.
A4268 CONTRACEPTIVE SUPPLY, CONDOM, FEMALE, EACH
A4269 CONTRACEPTIVE SUPPLY, SPERMICIDE (E.G., FOAM, GEL), EACH
J1050   Medroxyprogesterone acetate, 1 mg
J7296  Levonorgestrel-releasing intrauterine contraceptive system (Kyleena), 19.5 mg  
J7297 Levonorgestrel-releasing intrauterine contraceptive system, 52 mg, 3 year duration 
J7298  Levonorgestrel-releasing intrauterine contraceptive system, 52 mg, 5 year duration 
J7300   Intrauterine copper contraceptive
J7302 (code deleted 1/1/2016)  Levonorgestrel-releasing intrauterine contraceptive system (e.g., Mirena)
J7303 Contraceptive supply, hormone containing vaginal ring, each
J7304 Contraceptive supply, hormone containing patch, each
J7306   Levonorgestrel (contraceptive) implant system, including implants and supplies
J7307 Etonogestrel (contraceptive) implant system, including implant and supplies
Q9984 (code deleted 1/1/2018) Kyleena™ (levonorgestrel-releasing intrauterine system) 19.5 mg  
S4981   Insertion of levonorgestrel-releasing intrauterine system (e.g., Mirena)
S4989   Contraceptive intrauterine device (e.g., Progestasert IUD)
S4993 CONTRACEPTIVE PILLS FOR BIRTH CONTROL
Diagnosis codes:  
V15.7 PERSONAL HISTORY OF CONTRACEPTION, PRESENTING HAZARDS TO HEALTH
V25.01   Prescription of oral contraceptives
V25.02  Initiation of other contraceptive measures.
V25.03   Encounter for emergency contraceptive counseling and prescription.
V25.04   Counseling and instruction in natural family planning to avoid pregnancy
V25.09   Other family planning advice
V25.11   Encounter for insertion of intrauterine contraceptive device
V25.12   Encounter for removal of intrauterine contraceptive device
V25.13   Encounter for removal and reinsertion of intrauterine contraceptive device.
V25.2 Sterilization
V25.40 CONTRACEPTIVE SURVEILLANCE, UNSPECIFIED
V25.41   Contraceptive pill
V25.42  Intrauterine contraceptive device
V25.43  Implantable subdermal contraceptive
V25.49  Other contraceptive method
V25.5 Insertion of implantable subdermal contraceptive
V25.8 OTHER SPECIFIED CONTRACEPTIVE MANAGEMENT
V25.9 UNSPECIFIED CONTRACEPTIVE MANAGEMENT
V26.41 PROCREATIVE COUNSELING AND ADVICE USING NATURAL FAMILY PLANNING
V26.49 OTHER PROCREATIVE MANAGEMENT COUNSELING AND ADVICE
V26.51       TUBAL LIGATION STATUS
V45.51 PRESENCE OF INTRAUTERINE CONTRACEPTIVE DEVICE
V45.52 PRESENCE OF SUBDERMAL CONTRACEPTIVE IMPLANT
V45.59 PRESENCE OF OTHER CONTRACEPTIVE DEVICE
Z30.2  Encounter for sterilization 
996.32 Mechanical complication due to intrauterine contraceptive device
ICD-9 procedures:
66.21 BILATERAL ENDOSCOPIC LIGATION AND CRUSHING OF FALLOPIAN TUBES
66.22 BILATERAL ENDOSCOPIC LIGATION AND DIVISION OF FALLOPIAN TUBES
66.29 OTHER BILATERAL ENDOSCOPIC DESTRUCTION OR OCCLUSION OF FALLOPIAN TUBES
66.31 OTHER BILATERAL LIGATION AND CRUSHING OF FALLOPIAN TUBES
66.32 OTHER BILATERAL LIGATION AND DIVISION OF FALLOPIAN TUBES
66.39 OTHER BILATERAL DESTRUCTION OR OCCLUSION OF FALLOPIAN TUBES
66.51 REMOVAL OF BOTH FALLOPIAN TUBES AT SAME OPERATIVE EPISODE
66.52 REMOVAL OF REMAINING FALLOPIAN TUBE
66.92 UNILATERAL DESTRUCTION OR OCCLUSION OF FALLOPIAN TUBE
69.7 INSERTION OF INTRAUTERINE CONTRACEPTIVE DEVICE
97.71 REMOVAL OF INTRAUTERINE CONTRACEPTIVE DEVICE
ICD-10 Codes

Z920

 Personal History of contraception

Z30018

 Encounter for initial prescription of other contraceptives
Z30012 Encounter for prescription of emergency contraception
Z3009

Encounter for other general counseling and advice on contraception
Z3002 Counseling and instruction in natural family planning to avoid pregnancy
Z30430 Encounter for insertion of intrauterine contraceptive device
Z30432 Encounter for removal of intrauterine contraceptive device
Z302 Encounter for sterilization
Z3041 Encounter for surveillance of contraceptive pills
Z30431 Encounter for routine checking of intrauterine contraceptive device
Z3049 Encounter for surveillance of other contraceptives
Z308 Encounter for other contraceptive management
Z309 Encounter for contraceptive management, unspecified
Z3161 Procreative counseling and advice using natural family planning
Z3169 Encounter for other general counseling and advice on procreation
Z9851 Tubal ligation status
Z975 Presence of (intrauterine) contraceptive device
T8339XA Other mechanical complication of intrauterine contraceptive device, initial encounter
ICD-10 Procedures
0UPD7HZ Removal of Contraceptive Device from Uterus and Cervix, Via Natural or Artificial Opening
0UPD8HZ Removal of Contraceptive Device from Uterus and Cervix, Via Natural or Artificial Opening Endoscopic
0UH97HZ Insertion of Contraceptive Device into Uterus, Via Natural or Artificial Opening
0UH98HZ Insertion of Contraceptive Device into Uterus, Via Natural or Artificial Opening Endoscopic
0UHC7HZ Insertion of Contraceptive Device into Cervix, Via Natural or Artificial Opening
0UHC8HZ Insertion of Contraceptive Device into Cervix, Via Natural or Artificial Opening Endoscopic
0U550ZZ Destruction of Right Fallopian Tube, Open Approach
0U553ZZ Destruction of Right Fallopian Tube, Percutaneous Approach
0U554ZZ Destruction of Right Fallopian Tube, Percutaneous Endoscopic Approach
0U557ZZ Destruction of Right Fallopian Tube, Via Natural or Artificial Opening
0U558ZZ Destruction of Right Fallopian Tube, Via Natural or Artificial Opening Endoscopic
0U560ZZ Destruction of Left Fallopian Tube, Open Approach
0U563ZZ Destruction of Left Fallopian Tube, Percutaneous Approach
0U564ZZ Destruction of Left Fallopian Tube, Percutaneous Endoscopic Approach
0U567ZZ Destruction of Left Fallopian Tube, Via Natural or Artificial Opening
0U568ZZ Destruction of Left Fallopian Tube, Via Natural or Artificial Opening Endoscopic
0UL50CZ Occlusion of Right Fallopian Tube with Extraluminal Device, Open Approach
0UL50DZ Occlusion of Right Fallopian Tube with Intraluminal Device, Open Approach
0UL50ZZ Occlusion of Right Fallopian Tube, Open Approach
0UL53CZ Occlusion of Right Fallopian Tube with Extraluminal Device, Percutaneous Approach
0UL53DZ Occlusion of Right Fallopian Tube with Intraluminal Device, Percutaneous Approach
0UL53ZZ Occlusion of Right Fallopian Tube, Percutaneous Approach
0UL54CZ Occlusion of Right Fallopian Tube with Extraluminal Device, Percutaneous Endoscopic Approach
0UL54DZ Occlusion of Right Fallopian Tube with Intraluminal Device, Percutaneous Endoscopic Approach
0UL54ZZ Occlusion of Right Fallopian Tube, Percutaneous Endoscopic Approach
0UL57DZ Occlusion of Right Fallopian Tube with Intraluminal Device, Via Natural or Artificial Opening
0UL57ZZ Occlusion of Right Fallopian Tube, Via Natural or Artificial Opening
0UL58DZ Occlusion of Right Fallopian Tube with Intraluminal Device, Via Natural or Artificial Opening Endoscopic
0UL58ZZ Occlusion of Right Fallopian Tube, Via Natural or Artificial Opening Endoscopic
0UL60CZ Occlusion of Left Fallopian Tube with Extraluminal Device, Open Approach
0UL60DZ Occlusion of Left Fallopian Tube with Intraluminal Device, Open Approach
0UL60ZZ Occlusion of Left Fallopian Tube, Open Approach
0UL63CZ Occlusion of Left Fallopian Tube with Extraluminal Device, Percutaneous Approach
0UL63DZ Occlusion of Left Fallopian Tube with Intraluminal Device, Percutaneous Approach
0UL63ZZ Occlusion of Left Fallopian Tube, Percutaneous Approach
0UL64CZ Occlusion of Left Fallopian Tube with Extraluminal Device, Percutaneous Endoscopic Approach
0UL64DZ Occlusion of Left Fallopian Tube with Intraluminal Device, Percutaneous Endoscopic Approach
0UL64ZZ Occlusion of Left Fallopian Tube, Percutaneous Endoscopic Approach
0UL67DZ Occlusion of Left Fallopian Tube with Intraluminal Device, Via Natural or Artificial Opening
0UL67ZZ Occlusion of Left Fallopian Tube, Via Natural or Artificial Opening
0UL68DZ Occlusion of Left Fallopian Tube with Intraluminal Device, Via Natural or Artificial Opening Endoscopic
0UL68ZZ Occlusion of Left Fallopian Tube, Via Natural or Artificial Opening Endoscopic
0UT50ZZ Resection of Right Fallopian Tube, Open Approach
0UT54ZZ Resection of Right Fallopian Tube, Percutaneous Endoscopic Approach
0UT57ZZ Resection of Right Fallopian Tube, Via Natural or Artificial Opening
0UT58ZZ Resection of Right Fallopian Tube, Via Natural or Artificial Opening Endoscopic
0UT5FZZ Resection of Right Fallopian Tube, Via Natural or Artificial Opening With Percutaneous Endoscopic Assistance
0UT60ZZ Resection of Left Fallopian Tube, Open Approach
0UT64ZZ Resection of Left Fallopian Tube, Percutaneous Endoscopic Approach
0UT67ZZ Resection of Left Fallopian Tube, Via Natural or Artificial Opening
0UT68ZZ Resection of Left Fallopian Tube, Via Natural or Artificial Opening Endoscopic
0UT6FZZ Resection of Left Fallopian Tube, Via Natural or Artificial Opening With Percutaneous Endoscopic Assistance
0UT70ZZ  Resection of Bilateral Fallopian Tubes, Open Approach 
0UT74ZZ  Resection of Bilateral Fallopian Tubes, Percutaneous Endoscopic Approach 
0UT77ZZ  Resection of Bilateral Fallopian Tubes, Via Natural or Artificial Opening 
0UT78ZZ  Resection of Bilateral Fallopian Tubes, Via Natural or Artificial Opening Endoscopic 
0UT7FZZ  Resection of Bilateral Fallopian Tubes, Via Natural or Artificial Opening With Percutaneous Endoscopic Assistance 
0U570ZZ  Destruction of Bilateral Fallopian Tubes, Open Approach 
0U573ZZ  Destruction of Bilateral Fallopian Tubes, Percutaneous Approach 
0U577ZZ  Destruction of Bilateral Fallopian Tubes, Via Natural or Artificial Opening 
0UL70CZ Occlusion of Bilateral Fallopian Tubes with Extraluminal Device, Open Approach 
0UL70DZ  Occlusion of Bilateral Fallopian Tubes with Intraluminal Device, Open Approach 
0UL70ZZ  Occlusion of Bilateral Fallopian Tubes, Open Approach 
0UL73CZ  Occlusion of Bilateral Fallopian Tubes with Extraluminal Device, Percutaneous Approach 
0UL73DZ  Occlusion of Bilateral Fallopian Tubes with Intraluminal Device, Percutaneous Approach 
0UL73ZZ  Occlusion of Bilateral Fallopian Tubes, Percutaneous Approach 
0UL77DZ  Occlusion of Bilateral Fallopian Tubes with Intraluminal Device, Via Natural or Artificial Opening 
0UL77ZZ Occlusion of Bilateral Fallopian Tubes, Via Natural or Artificial Opening 
0UL70ZZ  Occlusion of Bilateral Fallopian Tubes, Open Approach 
0UL73ZZ  Occlusion of Bilateral Fallopian Tubes, Percutaneous Approach 
0UL77ZZ  Occlusion of Bilateral Fallopian Tubes, Via Natural or Artificial Opening 
0U574ZZ  Destruction of Bilateral Fallopian Tubes, Percutaneous Endoscopic Approach 
0U578ZZ  Destruction of Bilateral Fallopian Tubes, Via Natural or Artificial Opening Endoscopic 
0UL74CZ  Occlusion of Bilateral Fallopian Tubes with Extraluminal Device, Percutaneous Endoscopic Approach 
0UL74DZ Occlusion of Bilateral Fallopian Tubes with Intraluminal Device, Percutaneous Endoscopic Approach 
0UL74ZZ  Occlusion of Bilateral Fallopian Tubes, Percutaneous Endoscopic Approach 
0UL78DZ  Destruction of Bilateral Fallopian Tubes, Percutaneous Endoscopic Approach 
0UL78ZZ  Destruction of Bilateral Fallopian Tubes, Via Natural or Artificial Opening Endoscopic 
0UL74CZ  Occlusion of Bilateral Fallopian Tubes with Extraluminal Device, Percutaneous Endoscopic Approach 
0UL74DZ  Occlusion of Bilateral Fallopian Tubes with Intraluminal Device, Percutaneous Endoscopic Approach 
0UL74ZZ  Occlusion of Bilateral Fallopian Tubes, Percutaneous Endoscopic Approach
0UL78DZ  Occlusion of Bilateral Fallopian Tubes with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 
0UL78ZZ  Occlusion of Bilateral Fallopian Tubes, Via Natural or Artificial Opening Endoscopic 
0UL74ZZ  Occlusion of Bilateral Fallopian Tubes, Percutaneous Endoscopic Approach 
0UL78ZZ  Occlusion of Bilateral Fallopian Tubes, Via Natural or Artificial Opening Endoscopic 
 
DIABETES MELLITUS, SCREENING IN PREGNANT WOMEN 24 – 28 WEEKS GESTATION AND AT FIRST PRENATAL VISIT FOR PREGNANT WOMEN IDENTIFIED AS HIGH RISK FOR DIABETES
USPSTF Recommendation
The USPSTF recommends screening for gestational diabetes mellitus in asymptomatic pregnant women after 24 weeks of gestation. (Grade B)
 
CPT Codes:
CPT 82947
CPT 82948
CPT 82950
 
ICD-9 Codes:
V22.0 – V22.2
V23.0 – V23.9
V77.1 — screening for diabetes mellitus
 
ICD-10 Codes:
Z131
Z331
Z34 – Z3493
O0900 – O093
 
FOLIC ACID, PREVENTION OF NEURAL TUBE DEFECTS
USPSTF Recommendation
The USPSTF recommends that all women planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 to 800 µg) (Grade A) of folic acid. Not routinely covered for “all women capable of pregnancy.” (Grade A)
 
CPT/HCPCS Code:
A9152  
 
GONORRHEA, SCREENING
USPSTF Recommendation
The USPSTF recommends that clinicians screen all sexually active women, including those who are pregnant, for gonorrhea infection if they are at increased risk for infection (i.e., if young or have other individual or population. (Grade B)
 
HRSA (Bright Futures) Recommendation
Screen sexually active adolescents for gonorrhea using tests appropriate to the patient population and clinical setting.
 
CPT Codes:
CPT 87590
CPT 87591
CPT 87850
 
ICD-9 Codes:
V70.0
V72.3
V72.31
V74.5
V22.0 – V24.2
 
ICD-10 Codes:
Z0000
Z01411
Z01419
Z113
Z331
Z34 – Z3493
O0900 – O0933
Z390 – Z392
 
HEPATITIS B VIRUS INFECTION IN PREGNANCY, SCREENING
USPSTF Recommendation
The USPSTF strongly recommends screening for hepatitis B virus infection in pregnant women at their first prenatal visit (Grade A).
 
CPT Codes:
CPT 80055
CPT 80081
CPT 87340
 
ICD-9 Codes:
V22.0 – V22.2 — Prenatal visits
V23.0 – V23.9 — Prenatal visits for patients with high risk pregnancies
V28.9 — Antenatal screening NOS
 
ICD-10 Codes:
Z34 – Z3493
O0900 – O0993
Z36
 
HUMAN IMMUNODEFICIENCY VIRUS (HIV), COUNSELING AND SCREENING
USPSTF Recommendation
The USPSTF recommends that clinicians screen for human immunodeficiency virus (HIV) in adolescents and adults ages 15 – 65 years. Younger adolescents and older adults who are at increased risk should also be screened. (Grade A)
The USPSTF recommends that clinicians screen all pregnant women for HIV, including those who present in labor who are untested and whose HIV status is unknown. (Grade A)
 
HRSA (Bright Futures) Recommendation
Sexually active adolescents who are positive on risk questions should be screened for HIV.
 
CPT/HCPCS Codes:
CPT 86703
CPT 87389
CPT 87390
CPT 99401
CPT 99402
HCPCS G0432
HCPCS G0433
HCPCS G0435
HCPCS S3645
 
ICD-9 Codes:
V01.79
V22.0 – V24.2
 
ICD-10 Codes:
Z206
Z20828
Z331
Z34 – Z3493
O0900 – O0933 
  
INTIMATE PARTNER VIOLENCE, SCREENING/COUNSELING OF WOMEN, ANNUALLY
USPSTF Recommendation
The USPSTF recommends that clinicians screen women of childbearing age for intimate partner violence, such as domestic violence, and provide or refer women who screen positive to intervention services. This recommendation applies to women who do not have signs or symptoms of abuse.
 
CPT/HCPCS Codes:
CPT 99401 *CPT 99402 – CPT 99404 require review of records.
 
ICD-9 Code:
V61.11 — Counseling for victim of spousal and partner abuse
 
ICD-10 Code:
Z6911
 
IRON DEFICIENCY ANEMIA SCREENING IN PREGNANT WOMEN
USPSTF Recommendation
The USPSTF recommends routine screening for iron deficiency anemia in asymptomatic pregnant women. (Grade B).
 
CPT Codes:
CPT 80055
CPT 80081
CPT 85013
CPT 85014
CPT 85018
 
ICD-9 Codes:
V22.0 – V23.9
 
ICD-10 Codes:
Z331
Z34 – Z3493
O0900 – O0933 
   
OSTEOPOROSIS SCREENING IN WOMEN
USPSTF Recommendation
The USPSTF recommends screening for osteoporosis in women age 65 and older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors. (Grade B).
 
Verbiage updated in June 2018 does not impact coding:
 
The USPSTF recommends screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in postmenopausal women younger than 65 years who are at increased risk of osteoporosis, as determined by a formal clinical risk assessment tool.
 
The USPSTF recommends screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in women 65 years and older.
 
CPT Code:
CPT 77080
 
ICD-9 Code:
V82.81 Special screening for osteoporosis
 
ICD-10 Code:
Z13820
 
PRE-ECLAMPSIA PREVENTION: ASPIRIN
USPSTF Recommendations:
The USPSTF recommends the use of low-dose aspirin (81 mg/d) as preventive medication after 12 weeks of gestation in women who are at high risk for pre-eclampsia.
  
PRE-ECLAMPSIA SCREENING: BLOOD PRESSURE
 
April 2017 B recommendation:
 
The USPSTF recommends screening for pre-eclampsia in pregnant women with blood pressure measurements throughout pregnancy.
   
RH INCOMPATABILITY SCREENING
USPSTF Recommendations
The USPSTF strongly recommends Rh (D) blood typing and antibody testing for all pregnant women during their first visit for pregnancy-related care. (Grade A)
The USPSTF recommends repeated Rh (D) antibody testing for all unsensitized Rh (D)-negative women at 24 – 28 weeks' gestation, unless the biological father is known to be Rh (D)-negative. (Grade B)
 
CPT Codes:
CPT 80055
CPT 80081
CPT 86901
 
ICD-9 Codes:
V22.0 – V23.9 
 
ICD-10 Codes: 
Z331
Z34 – Z3493
O0900 – O0933
 
SCREENING FOR DIABETES MELLITUS AFTER PREGNANCY
HRSA recommends women with a history of gestational diabetes mellitus who are not currently pregnant and who have not previously been diagnosed with Type 2 diabetes mellitus should be screened for diabetes mellitus. Initial screening should ideally occur within the first year postpartum and can be conducted as early as 4 – 6 weeks postpartum. Women with a negative initial postpartum screening test result should be rescreened at least every 3 years for a minimum of 10 years after pregnancy.
 
CPT CODE
82951
 
ICD-9 CODE
V12.21
 
ICD-10 CODE
Z86.32
 
SCREENING FOR URINARY INCONTINENCE
HRSA recommends screening women for urinary incontinence annually.
 
CPT CODES
99401
1090f
 
SEXUALLY TRANSMITTED INFECTIONS (STIs); BEHAVIORAL COUNSELING TO PREVENT
USPSTF Recommendation
The USPSTF recommends high intensity behavioral counseling to prevent sexually transmitted infections (STIs) for all sexually active adolescents and for adults at increased risk for STIs. (Grade B)
 
CPT Codes:
CPT 99401
CPT 99402
 
ICD-9 Codes:
V65.44 — Human immunodeficiency virus counseling
V65.45 — Counseling on other sexually transmitted diseases
V69.2 — Problems related to high-risk sexual behavior
 
ICD-10 Codes:
Z717
Z7189
Z7251 — Z7253
   
SYPHILIS, SCREENING
USPSTF Recommendation
The USPSTF recommends that clinicians screen all persons at increased risk for syphilis infection, and all pregnant women for syphilis infection. (Grade A)
 
HRSA (Bright Futures) Recommendation
Bright Futures recommends screening for syphilis in all adolescents who are sexually active and positive for high risk.
 
CPT Codes:
CPT 80055
CPT 80081
CPT 86592
CPT 86780
 
ICD-9 Codes:
V22.0 – V23.9
V69.2
V74.5 
 
ICD-10 Codes:
Z331
Z34 – Z3493
O0900 – O0993
Z7251
Z113
Z7251 – Z7253
 
TOBACCO USE, SCREENING, COUNSELING AND INTERVENTIONS
USPSTF Recommendation
The USPSTF recommends that clinicians ask all adults about tobacco use, advise them to stop using tobacco and provide behavioral interventions and U.S. Food and Drug Administration (FDA)-approved pharmacotherapy for cessation to adults who use tobacco.
(Grade A)
 
The USPSTF recommends that clinicians ask all pregnant women about tobacco use, advise them to stop using tobacco and provide behavioral interventions for cessation to pregnant women who use tobacco.
(Grade A)
 
The USPSTF recommends that clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use in school-aged children.
 
CPT Codes:
CPT 99406
CPT 99407
 
ICD-9 Codes:
305.1 — Tobacco dependence
649.01 – 649.04 — Smoking complicating pregnancy
V15.82 — History of tobacco use
V15.89 — Other specified personal history presenting hazards to health, Other
 
ICD-10 Codes:
F17200
O99331 – O9335
Z87891
Z779
Z9289
 
Well-woman preventive care visit is recommended annually to obtain the recommended preventive services that are age and developmentally appropriate.
 
NOTE: The procedure filed will be used to determine no cost share issues, not the diagnosis filed.

Gynecological:

S0610      ANNUAL GYNECOLOGICAL EXAMINATION, NEW PATIENT

S0612      ANNUAL GYNECOLOGICAL EXAMINATION, ESTABLISHED PATIENT

S0613      ANNUAL GYNECOLOGICAL EXAMINATION; CLINICAL BREAST EXAMINATION WITHOUT PELVIC EVALUATION

New Patient:

99384      (Age 12 – 17) INITIAL COMPREHENSIVE PREVENTIVE MEDICINE EVALUATION AND MANAGEMENT

99385      (Age 18 – 39) INITIAL COMPREHENSIVE PREVENTIVE MEDICINE EVALUATION AND MANAGEMENT

99386      (Age 40 – 64) INITIAL COMPREHENSIVE PREVENTIVE MEDICINE EVALUATION AND MANAGEMENT

99387      (Age 65 year and older) INITIAL COMPREHENSIVE PREVENTIVE MEDICINE EVALUATION AND MANAGEMENT

Established Patient:

99394      (Age 12 – 17) PERIODIC COMPREHENSIVE PREVENTIVE MEDICINE REEVALUATION AND MANAGEMENT

99395      (Age 18 – 39) PERIODIC COMPREHENSIVE PREVENTIVE MEDICINE REEVALUATION AND MANAGEMENT

99396      (Age 40 – 64) PERIODIC COMPREHENSIVE PREVENTIVE MEDICINE REEVALUATION AND MANAGEMENT

99397      (Age 65 years and older) PERIODIC COMPREHENSIVE PREVENTIVE MEDICINE REEVALUATION AND MANAGEMENT

Annual Wellness Visit:

G0438      ANNUAL WELLNESS VISIT; INCLUDES A PERSONALIZED PREVENTION PLAN

G0439      ANNUAL WELLNESS VISIT, INCLUDES A PERSONALIZED PREVENTION PLAN

S5190      WELLNESS ASSESSMENT, PERFORMED BY NON-PHYSICIAN

ICD-9 Codes:

V72.3 Gynecological examination

V72.31 Routine gynecological examination 

ICD-10 Code:

Z01419

Reference 
  1. Internet Citation: USPSTF A and B Recommendations, U.S. Preventive Services Task Force. October 2014  http://www.uspreventiveservicestaskforce.org/Page/Name/upstf-a-and-b-recommendations/ 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2015 Forward     

05/01/2023 Corrected typo under Breast Cancer, Screening (MAMMOGRAPHY) section. No other changes made to policy.
02/22/2023 Adding 00851 code to coding section. No other changes.
12/21/2022 Annual review, no change to policy intent
10/12/2022 Interim review to add contraceptive for male condoms and FDA approved web application/digital contraception. Adding note regarding requirements for receipt to be provided for any over the counter or self purchased contraception. Also adding ICD 9 code V7619 to the mammography section of the policy. No other changes made.
08/11/2022 Adding G0144 and G0145 to cervical cancer screening coding. No other changes.

02/09/2022 

Interim review adding procedure codes 58670 and 58661 to the contraception section of the policy IF filed with diagnosis Z30.2. No other changes. 

12/01/2021 

Annual review, no change to policy intent. 

12/03/2020 

Annual review, no change to policy intent. 

12/03/2019 

Annual review, no change to policy intent. 

1/31/2019 

Updated coding section. No other changes. 

12/20/2018 

 Updated Last review date.

12/13/2018 

Annual review, updating osteoporosis screening verbiage. This update does not impact coding related to the recommendation. 

07/23/2018

 Interim review to add Z113 & V745 in relation to gonorrhea testing. No other changes made.

04/18/2018 

Interim Review. Breast screening added verbiage to cpt/hcpc codes 77052, 77057 and 77067, breast cancer preventive medication correct typo Z83 to Z2803. Diabetes Mellitus,screening in pregnant woment 24 – 28 weeks added icd10 code Z131 and removed Z390-Z392.IN HEPATITIS B VIRUS INFECTION IN PREGNANCY, SCREENING removed ICD-10 Z331. In Human Immunodeficiency Virus, couseling and screening added Cpt codes 99401, 99402 and added HCPCS code G0435, S3645.

04/10/2018 

Interim review to add new recommendations regarding diabetes mellitus screening after pregnancy and screening for urinary incontinence annually. 

12/12/2017 

Updating policy with Bright Futures recommendations. 

12/7/2017 

Annual review, adding note regarding the requirement of 96372 to be filed on the same date as J1050 for no cost share to apply.  Updated coding. No other changes made. 

11/21/2017 

Updated policy to add code J7296. No other changes. 

11/06/2017 

Adding Code V73.81 to coding. No other changes.

10/30/2017 

Correcting Code Q8894 to Q9984. No other changes. 

10/09/2017 

Updating Contraception coding with HCPCS Q8894. No other changes. 

08/21/2017 

Interim review to add USPSTF recommendation regarding pre-eclampsia blood pressure screening. No other changes. 

06/08/2017 

Interim review to add record review statement for codes 99402-99404. 

12/28/2016 

Annual review, adding new cpt code 77067 to the breast cancer screening portion of the policy. 

06/02/2016 

Semi annual review, updating tobacco cessation verbiage to match the most current USPSTF verbiage and current preeclampsia verbiage. This does not change the policy intent. 

03/21/2016 

Added code Z1151 to cervical screening section. 

01/14/2016 

Updating, adding additional 2016 codes, adding ICD-10 procedure codes in contraception section. 

01/11/2016 

Interim review, adding codes J7298 & J7297 in the contraception area of the policy to address the medication in deleted code J7302. 

12/1/2015 

Interim review to add CPT 96372 as it relates to administration in the contraception area of the policy.

09/22/2015

Added ICD-10 coding to policy. 

06/10/2015 

Interim review, updating HPV coding to include 87623 – 84625 every 5 years. Also added code range 87623 – 87625 to the coding for cervical cancer screening/HPV and adding code range 87621 – 87625 to HPV & cervical cancer screening.

06/01/2015

NEW POLICY

 
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