ACA Preventive Care Coding Guidelines effective January 1, 2026 Form

Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Community Care Health Plan of Nevada, Inc. and Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In 17 southeastern counties of New York: Anthem HealthChoice Assurance, Inc. and Anthem HealthChoice HMO, Inc. In these same counties, Anthem Blue Cross and Blue Shield HP is the trade name of Anthem HP, LLC and Anthem Blue Cross and Blue Shield Retiree Solutions is the trade name of Anthem Insurance Companies, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. Anthem Blue Cross and Blue Shield and its affiliate Healthkeepers, Inc. serve all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI). BCBSWI underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. MULTI-BCBS-CM-003812-25-GRP1128 | February 2026

ACA preventive care coding guidelines

Colorado • Connecticut • Georgia • Indiana • Kentucky • Maine • Missouri • Nevada • New Hampshire • New York • Ohio • Virginia • Wisconsin | Anthem Blue Cross and Blue Shield | Commercial

Introduction As part of our commitment to deliver holistic member-centered care, Anthem acknowledges the paramount importance of preventive care services in reducing the burden of illness and augmenting the overall health of our community. By equipping healthcare providers with the knowledge and tools to administer evidence-based preventive services, we hope to underscore the pivotal role of preventive services such as screenings, behavioral counseling, and preventive medications in safeguarding the health and well-being of our members. As required by the Affordable Care Act (ACA), Anthem provides coverage of all recommended services outlined below under the preventive care services benefit.
Anthem adheres to the preventive service recommendations provided by the following: • United States Preventive Services Task Force (USPSTF) recommendations that have a rating of A or B • Immunizations that are recommended and determined to be for routine use by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention • Health Resources and Services Administration (HRSA) guidelines with respect to infants, children, and adolescents recommended by the Bright Futures Project • HRSA guidelines with respect to women recommended by the Women’s Preventive Services Initiative (WPSI)

These recommendations encompass a comprehensive array of screenings, vaccinations, counseling, and preventive medications to address various health risks and conditions. Key provisions Recommended services

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Cost-share waiver for in-network providers Members who receive preventive services from an in-network healthcare provider are eligible for a cost-sharing waiver. This waiver includes the waiver of copays, deductibles, and coinsurance for eligible preventive services. Thus, these services will be provided without cost to members when provided by a network provider.

Note: All routine immunizations deemed medically necessary and recommended by the American Academy of Pediatrics and the American Academy of Family Physicians will be provided at no cost.

Grandfathered plans Anthem acknowledges the existence of “grandfathered” health plans, which are those in existence on or before March 23, 2010. While these plans may have specific exemptions,
Anthem endeavors to align the provision of preventive services under these plans with the standards outlined in this policy, to the extent allowed.

Preventive service definition Services encompassing screenings, vaccinations, counseling, and interventions intended to prevent or detect health issues at an early stage. Preventive services are, by definition, services provided to asymptomatic persons and are not diagnostic procedures to determine the nature and origin of existing health concerns, resulting in a specific diagnosis to guide treatment decisions.
Vaccinations Vaccinations shall be administered in accordance with the vaccination schedule recommended and determined to be for routine use by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention. ACIP guidelines should be followed in regard to age groups and populations for the vaccine to be considered preventive. Breastfeeding equipment and supplies The following breastfeeding equipment is considered preventive when purchased from an in- network Home Medical Equipment supplier: • One personal-use electric breast pump per pregnancy. • Replacement breast pump supplies necessary for the personal-use electric breast pump to operate, including: standard power adaptor, tubing adaptors, tubing, locking rings, bottles specific to breast pump operation, caps for bottles that are specific to the breast pump, valves, filters, and breast shield and/or splash protector for use with the breast pump.
• Replacement parts are provided at no cost as needed.

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A breast pump purchase includes the necessary supplies for the pump to operate. Thus, replacement supplies are not allowed with the original purchase of the breast pump, as they are included in the purchase of the pump. Limitations and exclusions Certain services, despite falling under the broader category of healthcare, are not considered preventive services under this policy. These services include, but are not limited to: • Prescription drugs covered under the member's prescription drug benefit plan. Please refer to the pharmacy benefit plan for further information on prescription drugs covered as preventive. • Services deemed diagnostic in nature, as previously defined. • Vaccination services: – Vaccines are only considered preventive when used in compliance with FDA labeling as a preventive vaccine. – Services obtained for non-medical reasons are not considered preventive. These include, but are not limited to: o Travel requirements o Employment, school or educational, marriage or adoption, court or judicial, and sports or camp-mandated services o Medical research o Maintenance of a license • Investigational, experimental, unproven, not medically necessary, or off-label services are not considered preventive.

Please note that services not covered under the preventive care benefit may be covered under another portion of the medical benefit plan. Members or their providers are encouraged to consult the member's respective healthcare plans for coverage details pertaining to the above excluded services, as they may still hold significant value in managing health concerns and promoting overall well-being. This information is intended as a reference tool for your convenience and is not a guarantee of payment.
Reasonable medical management The ACA states reasonable medical management techniques may be used to determine coverage limitations if a recommendation or guideline does not specify the frequency, method, treatment, or setting for the provision of a recommended preventive service. Reasonable medical management techniques may include precertification, concurrent review, claim review, or similar practices to determine coverage limitations under the plan. These established, reasonable medical management techniques and practices may be used to determine

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frequency, method, treatment, or setting for the provision of a recommended preventive service. Correct coding
Correct coding edits will still be applied, and, as such, some services may be considered bundled when submitted on the same date. When screening services, counseling services, medical nutrition therapy services, and visual function and visual acuity screening services are performed on the same date of service by the same specialty physician or other qualified healthcare professional as a wellness visit, only the preventive medicine code is reimbursable.

All codes, procedures, and diagnoses billed for preventive services should follow standard coding guidelines, including those related to modifier 25 and unacceptable primary and principal diagnoses.
Modifier 33 Modifier 33: Preventive service; when the primary purpose of the service is the delivery of an evidence-based service in accordance with a USPSTF A or B rating in effect, and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. For separately reported services specifically identified as preventive, the modifier should not be used.

Note: Anthem considers the procedures, diagnostic codes, and instructions listed in this policy to determine whether preventive care benefits apply. While modifier 33 may be reported, it will not be used to determine preventive care benefits. Acronyms Throughout this document, the following acronyms are used:
• USPSTF: United States Preventive Services Task Force
• ACA: Affordable Care Act of 2010
• ACIP: Advisory Committee on Immunization Practices
• HRSA: Health Resources and Services Administration • BF: Bright Futures, a national health promotion and prevention initiative, led by the American Academy of Pediatrics and supported, in part, by the United States Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB)

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New and updated recommendations Guidelines for preventive services are regularly updated to reflect new scientific and medical advances. As new recommendations and updates to existing ones are published, health plans have one year to implement the recommendation (full coverage for new and updated recommendations will occur within at least one year after the latest issue date, beginning in the next plan year, unless one of the recommending bodies determines that a service is discouraged because it is harmful or poses a significant safety concern; in these circumstances, federal guidance will be issued).

Anthem will update these coding guidelines based on new or revised laws and/or regulations, additional guidance, and Anthem policies. Guidelines All applicable diagnosis codes for preventive services should be billed in the primary position on the claim or as a primary diagnosis pointer, as benefits are based on the primary diagnosis billed with the corresponding procedure code(s).

The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all-inclusive as benefit coverage for health services is determined by the member specific benefit plan document and applicable laws. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. CPT® is a registered trademark of the American Medical Association.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Wellness Visits Wellness examinations, by definition, include the following:
• An age and gender appropriate history • Physical examination • Age-appropriate counseling for patients/parents • Anticipatory guidance for patients/parents • Risk factor reduction interventions • The ordering of laboratory and diagnostic procedures. Wellness Visits Wellness Visit — Infant Younger than 1 year 99381, 99391, 99461 Z00.110, Z00.111, Z00.121, Z00.129 Wellness visits do not require a diagnosis code for the preventive benefit to apply. However, appropriate diagnosis codes should be submitted.

The American Academy of Pediatrics (AAP) Bright Futures Periodicity Schedule should be followed from birth through twenty-one (21) years of age.

A yearly wellness visit should occur after age twenty-one (21).

Wellness Visit — Early Childhood Age 1–4 years 99382, 99392 Z00.121, Z00.129 Wellness Visit — Late Childhood Age 5–11 years 99383, 99393 Z00.121, Z00.129 Wellness Visit — Adolescent Age 12–17 years 99384, 99394, 99459 Z00.121, Z00.129 Wellness Visit 18 years and older 99385, 99386, 99387, 99395, 99396, 99397, 99459 Z00.00, Z00.01

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Wellness Visits Annual Wellness Examination 99459, S0610, S0612, S0613, G0402, G0438, G0439 Z00.00, Z00.01, Z01.411, Z01.419, Z12.31, Z12.4, Z12.72 An annual well-woman exam should occur beginning at adolescence.

Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Assessments and Counseling Behavioral assessments (Bright Futures)

Grade: N/A

Population:
All children Bright Futures recommends physicians conduct psychosocial/behavioral assessment at each of the recommended visits between newborn and 21 years. Counseling: 99401, 99402, 99403, 99404, 99411, 99412

Screening: 96127 Counseling and Screening:
Z13.31, Z13.39 Age 21 years and younger

Normally considered part of wellness office visit.

Requires a listed diagnosis code for the preventive benefit to apply if provided outside of a preventive visit.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Assessments and Counseling Hypertension in Adults: Screening (USPSTF)

Grade: A

Population:
Adults 18 years or older without known hypertension The USPSTF recommends screening for hypertension in adults 18 years or older with office blood pressure measurement (OBPM).

The USPSTF recommends obtaining blood pressure measurements outside of the clinical setting for diagnostic confirmation before starting treatment. 93784, 93786, 93788, 93790 R03.0 Age 18 years or older

Blood pressure screenings are considered part of wellness office visit.

Requires a listed diagnosis code for the preventive benefit to apply if provided outside of a preventive visit.
Anxiety Screening (USPSTF and WPSI)

Grade: N/A

Population:
Adults 64 years or younger, including pregnant and postpartum persons
The USPSTF recommends screening for anxiety disorders in adults, including pregnant and postpartum persons.

The Women's Preventive Services Initiative recommends screening for anxiety in adolescent and adult women, including those who are pregnant or postpartum.
Counseling: 99401, 99402, 99403, 99404, 99411, 99412

Screening: 96127, 96160, 96161 Counseling and Screening: Z13.30, Z13.39 Age 18 through 64 years

Normally considered part of wellness office visit.

Requires a listed diagnosis code for the preventive benefit to apply if provided outside of a preventive visit.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Assessments and Counseling Healthy Diet and Physical Activity for Cardiovascular Disease Prevention in Adults With Cardiovascular Risk Factors: Behavioral Counseling Interventions (USPSTF)

Grade: B

Population:
Adults with cardiovascular disease risk factors The USPSTF recommends offering or referring adults with cardiovascular disease risk factors to behavioral counseling interventions to promote a healthy diet and physical activity. Counseling: 99401, 99402, 99403, 99404

Medical Nutrition Therapy or Counseling: 97802, 97803, 97804, S9470, G0270, G0271

Behavioral Counseling or Therapy: 0403T, G0446, G0447, G0473

ASCVD Risk Assessment and Risk Management Services: G0537, G0538 Z71.3, Z83.42 Normally considered part of wellness office visit.

Requires a listed diagnosis code for the preventive benefit to apply if provided outside of a preventive visit.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Assessments and Counseling Intimate Partner Violence, Elder Abuse, and Abuse of Vulnerable Adults: Screening (USPSTF and WPSI)

Grade: B

Population:
Women of reproductive age The USPSTF recommends that clinicians screen for intimate partner violence (IPV) in women of reproductive age and provide or refer women who screen positive to ongoing support services.
99401, 99402, 99403, 99404 Z69.11, Z69.8
Normally considered part of wellness office visit.

Requires a listed diagnosis code for the preventive benefit to apply if provided outside of a preventive visit.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Assessments and Counseling Obesity Prevention in Midlife Women
(WPSI)

Grade: N/A

Population:
Women 40–60 with normal or overweight BMI The Women’s Preventive Services Initiative (WPSI) recommends counseling midlife women aged 40 to 60 years with a normal or overweight body mass index (BMI) (18.5–29.9 kg/m²) to maintain their weight or limit weight gain to prevent obesity. Counseling may include individualized discussion of healthy eating and physical activity. Medical Nutrition Therapy: 97802, 97803, 97804, G0270, G0271, S9470

Preventive Medicine Individual Counseling: 99401, 99402, 99403, 99404

Behavioral Counseling or Therapy: 0403T, G0446, G0447, G0473, 0488T Primary Diagnosis Codes:
Z71.3, Z72.3, Z72.4

Secondary Diagnosis Codes:
Body Mass Index 30.0- 39.9: Z68.30, Z68.31, Z68.32, Z68.33, Z68.34, Z68.35, Z68.36, Z68.37, Z68.38, Z68.39

Body mass index 40.0 and over: Z68.41, Z68.42, Z68.43, Z68.44, Z68.45

Obesity:
E66.01, E66.09, E66.1, E66.8, E66.9 Age 40 through 60 years

Counseling is normally considered part of wellness office visit.

Requires a listed diagnosis code for the preventive benefit to apply if provided outside of a preventive visit.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Assessments and Counseling Urinary Incontinence Screening (WPSI)

Grade: N/A

Population:
Women The Women’s Preventive Services Initiative recommends screening women for urinary incontinence annually.
99401, 99402, 99403, 99404 Z13.89 Normally considered part of wellness office visit.

Requires a listed diagnosis code for the preventive benefit to apply if provided outside of a preventive visit. Sexually Transmitted Infections: Behavioral Counseling (USPSTF and WPSI)

Grade: B

Population:
Sexually active adolescents and adults at increased risk The USPSTF recommends behavioral counseling for all sexually active adolescents and for adults who are at increased risk for sexually transmitted infections (STIs). See the Practice Considerations section for more information on populations at increased risk for acquiring STIs. 99401, 99402, 99403, 99404, 99411, 99412, G0445 Z11.3, Z11.8 Normally considered part of wellness office visit.

Requires a listed diagnosis code for the preventive benefit to apply if provided outside of a preventive visit.G0445 is limited to twice a year.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Assessments and Counseling Anxiety in Children and Adolescents: Screening (USPSTF)

Grade: B

Population:
Children and adolescents The USPSTF recommends screening for anxiety in children and adolescents aged 8 to 18 years. Counseling: 99401, 99402, 99403, 99404, 99411, 99412

Screening: 96127, 96160, 96161 Counseling and Screening: Z13.30, Z13.39 Age 8 through 18 years

Counseling normally considered part of wellness office visit.

Requires a listed diagnosis code for the preventive benefit to apply if provided outside of a preventive visit.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Assessments and Counseling Height, weight, and body mass index measurements (Bright Futures)

Grade: N/A

Population:
All children Establish procedures for intervening with children and adolescents who have overweight BMI (≥85th–94th percentile BMI) or obesity (≥95th percentile BMI).43 For instance, when a child or adolescent is overweight, a healthcare professional can review family history, the child's or adolescent's blood pressure and cholesterol, and BMI percentile over time and then assess health risk according to that information. Staff should flag charts of children and adolescents with overweight or obesity, so all staff at all visits are aware of the problem and can monitor growth, risk factors, and social and emotional issues.

Considered part of wellness office visit.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Assessments and Counseling Oral health risk assessment (Bright Futures)

Grade: N/A

Population:
Young children Bright Futures recommends that healthcare professionals conduct an oral health risk assessment when an infant is 6 months of age. This assessment consists of the healthcare professional asking parents about their and the child’s oral health practices and examining the child’s mouth to assess the risk of caries.

Skin Cancer Prevention: Behavioral Counseling (USPSTF)

Grade: B

Population:
Young adults, adolescents, children, and parents of young children The USPSTF recommends counseling young adults, adolescents, children, and parents of young children about minimizing exposure to ultraviolet (UV) radiation for persons aged 6 months to 24 years with fair skin types to reduce their risk of skin cancer.

Considered part of wellness office visit.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Assessments and Counseling Blood Pressure Screening (Bright Futures)

Grade: N/A

Population:
All children Bright Futures recommends that children and adolescents aged 3 to 17 years receive blood pressure screening during their annual preventive care visit. 93784, 93786, 93788, 93790 R03.0 Age 3 through 17 years

Blood pressure screenings are considered part of wellness office visit.

Requires a listed diagnosis code for the preventive benefit to apply if provided outside of a preventive visit.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Immunizations Vaccines Recommended by the Centers for Disease Control's Advisory Committee on Immunization Practices (ACIP)

Population:
18 years and younger COVID-19 Administration: 90480, M0201

Immunization:
91318 (6 months to 4 years)
91321 (6 months to 11 years) 91319 (5 to 11 years) 91304, 91320 (12 years and older) Z23 The listed diagnosis code is requested but not required for the preventive benefit to apply.

Please refer to the CDC's immunization schedule for recommended vaccinations by age.

If an evaluative or preventive service is being coded and billed with an injection, it must be appended with an appropriate modifier, such as -25 or -59, to indicate the services are separate and distinct.

Please refer to the plan's pharmacy benefit for details on vaccine options available under the plan's pharmacy preventive benefit. Diphtheria, tetanus, and pertussis Administration:
90460, 90461, 90471, 90472

Immunization:
90696, 90697, 90698, 90700, 90702, 90714, 90715, 90723 Z23 Hepatitis A Administration:
90460, 90461, 90471, 90472

Immunization:
90633, 90634 Z23

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Immunizations Hepatitis B Administration:
90460, 90461, 90471, 90472, G0010, M0201

Immunization:
90740, 90743, 90744, 90747 Z23 Human Papillomavirus Administration:
90460, 90461, 90471, 90472

Immunization:
90649, 90650, 90651 Z23 Inactivated Poliovirus Administration:
90460, 90461, 90471, 90472

Immunization:
90713 Z23 Vaccines Recommended by the Centers for Disease Control's Influenza — Flu Shot Administration:
90460, 90461, 90471, 90472, 90473, 90474, G0008, M0201 Z23 The listed diagnosis code is requested but not required for the preventive benefit to apply. Please refer to the CDC's immunization

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Immunizations Advisory Committee on Immunization Practices (ACIP)

Population:
18 years and younger

Immunization:
90653, 90655, 90656, 90657, 90658, 90660, 90661, 90662, 90672, 90673, 90674, 90682, 90685, 90686, 90687, 90688, 90689, 90756, 90694, Q2039, Q2034, Q2035, Q2036, Q2037, Q2038 schedule for recommended vaccinations by age. If an evaluative or preventive service is being coded and billed with an injection, it must be appended with an appropriate modifier, such as -25 or -59, to indicate the services are separate and distinct. Please refer to the plan’s pharmacy benefit for details on vaccine options available under the plan’s pharmacy preventive benefit. Measles Administration:
90460, 90461, 90471, 90472

Immunization:
90707, 90710 Z23 Meningococcal Administration:
90460, 90461, 90471, 90472

Immunization:
90619, 90620, 90621, 90623, 90624, 90644, 90733, 90734 Z23 Mumps Administration:
90460, 90461, 90471, 90472 Z23

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Immunizations

Immunization:
90707, 90710 Pneumococcal Administration:
90460, 90461, 90471, 90472, M0201

Immunization:
90670, 90671, 90677, 90732 Z23 Respiratory syncytial virus (RSV) Administration:
96380, 96381

Immunization:
90380, 90381 Z23 Vaccines Recommended by the Centers for Disease Control's Advisory Committee on Immunization Practices (ACIP) Rotavirus Administration:
90460, 90461, 90473, 90474

Immunization:
90680, 90681 Z23 The listed diagnosis code is requested but not required for the preventive benefit to apply. Please refer to the CDC's immunization schedule for recommended vaccinations by age. If an evaluative or preventive service is being coded and billed with an injection, it must be appended with an appropriate Rubella Administration:
Z23

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Immunizations

Population:
18 years and younger 90460, 90461, 90471, 90472

Immunization:
90707, 90710 modifier, such as -25 or -59, to indicate the services are separate and distinct. Please refer to the plan’s pharmacy benefit for details on vaccine options available under the plan’s pharmacy preventive benefit. Varicella — Chickenpox Administration:
90460, 90461, 90471, 90472

Immunization:
90396, 90716 Z23 Vaccines Recommended by the Centers for Disease Control's Advisory Committee on Immunization Practices (ACIP)

Population:
19 years and older COVID-19 Administration:
90480, M0201

Immunization:
91304, 91320, 91322 Z23 The listed diagnosis code is requested but not required for the preventive benefit to apply. Please refer to the CDC's immunization schedule for recommended vaccinations by age. If an evaluative or preventive service is being coded and billed with an injection, it must be appended with an appropriate modifier, such as -25 or -59, to indicate the services are separate and distinct. Please refer to the plan's pharmacy benefit for details on Diphtheria, tetanus, and pertussis Administration:
90460, 90461, 90471, 90472

Immunization:
Z23

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Immunizations 90696, 90697, 90698, 90700, 90702, 90714, 90715, 90723 vaccine options available under the plan's pharmacy preventive benefit. Haemophiles Influenzae Type B Administration:
90471, 90472

Immunization:
90644, 90647, 90648, 90697, 90698, 90748 Z23 Hepatitis A Administration:
90471, 90472

Immunization:
90632, 90633, 90634, 90636 Z23 Hepatitis B Administration:
90471, 90472, G0010, M0201

Immunization:
90739, 90740, 90746, 90747, 90748, 90636, 90759 Z23

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Immunizations Human Papillomavirus Administration:
90460, 90461, 90471, 90472

Immunization:
90649, 90650, 90651 Z23 Influenza Administration:
90471, 90472, 90473, 90474, G0008, M0201

Immunization:
90653, 90655, 90656, 90657, 90658, 90660, 90661, 90662, 90672, 90673, 90674, 90682, 90685, 90686, 90687, 90688, 90689, 90756, 90694, Q2039, Q2034, Q2035, Q2036, Q2037, Q2038 Z23 Vaccines Recommended by the Centers for Disease Control's Advisory Committee on Measles, Mumps, and Rubella Administration:
90460, 90461, 90471, 90472

Immunization:
90707, 90710 Z23 The listed diagnosis code is requested but not required for the preventive benefit to apply. Please refer to the CDC's immunization schedule for recommended vaccinations by age. If an evaluative or preventive service is being coded

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Immunizations Immunization Practices (ACIP)

Population:
19 years and older Meningococcal Administration:
90460, 90461, 90471, 90472

Immunization:
90619, 90620, 90621, 90623, 90624, 90644, 90733, 90734 Z23 and billed with an injection, it must be appended with an appropriate modifier, such as -25 or -59, to indicate the services are separate and distinct. Please refer to the plan’s pharmacy benefit for details on vaccine options available under the plan’s pharmacy preventive benefit. Pneumococcal Administration:
90460, 90461, 90471, 90472, G0009, M0201

Immunization:
90670, 90671, 90677, 90684, 90732 Z23 Respiratory Syncytial Virus Administration:
90471, 90472

Immunization:
90678, 90679, 90683 Z23 Smallpox and Monkeypox Administration:
90471, 90472 Z23

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Immunizations

Immunization: 90611, 90622
Td booster, Tdap Administration:
90471, 90472

Immunization:
90714, 90715 Z23 Vaccines Recommended by the Centers for Disease Control's Advisory Committee on Immunization Practices (ACIP)

Population:
19 years and older Varicella — Chickenpox Administration:
90471, 90472

Immunization:
90396, 90716 Z23 The listed diagnosis code is requested but not required for the preventive benefit to apply. Please refer to the CDC's immunization schedule for recommended vaccinations by age. If an evaluative or preventive service is being coded and billed with an injection, it must be appended with an appropriate modifier, such as -25 or -59, to indicate the services are separate and distinct. Please refer to the plan’s pharmacy benefit for details on vaccine options available under the plan’s pharmacy preventive benefit. Zoster — Shingles Administration:
90471, 90472

Immunization:
90736, 90750 Z23

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Breast Cancer Screenings Breast Cancer: Screening (USPSTF and WPSI)

Grade: B

Population: Women 40 to 74 years of age The USPSTF recommends biennial screening mammography for women aged 40 to 74 years.

The Women's Preventive Services Initiative recommends, as a preventive service, that women initiate mammography screening no earlier than age 40 and no later than age 50 and continue through at least age 74. Screening mammography should occur at least biennially and as frequently as annually. Mammography: 77065, 77066, 77067

MRI: C8903, C8905, C8906, C8908, C8937 MRI Contrast Material: A9576, A9577, A9578, A9581, Q9953, Q9954

Tomosynthesis: 77061, 77062, 77063, G0279

Ultrasound: 76641, 76642

Pathology: 19081, 19082, 19083, 19084, 19085, 19086, 19100, 19101 Mammography and Tomosynthesis:
Z12.31, Z12.39

MRI, Ultrasound, and Pathology: R92.0, R92.1, R92.2, R92.3, R92.4, R92.5, R92.6, R92.7, R92.8, Z12.31, Z12.39 Age 40 to 74 years

77063 and 77067 do not require a diagnosis code for the preventive benefit to apply. However, the diagnosis code listed is requested. All other procedures require a diagnosis code for the preventive benefit to apply.

The following screening intervals should be applied: • Women ages 40 to 44 should have the choice to start annual breast cancer screening with mammograms (X-rays of the breast) if they wish to do so. • Women ages 45 to 54 should get mammograms every year. Women 55 and older should switch to mammograms every two years or can continue yearly screening.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Breast Cancer Screenings BRCA-Related Cancer: Risk Assessment, Genetic Counseling, and Genetic Testing (USPSTF)

Grade: B

Population:
Women with a personal or family history of breast, ovarian, tubal, or peritoneal cancer, or an ancestry associated with the BRCA1/2 gene mutation The USPSTF recommends that primary care clinicians assess women with a personal or family history of breast, ovarian, tubal, or peritoneal cancer or who have an ancestry associated with breast cancer susceptibility 1 and 2 (BRCA1/2) gene mutations with an appropriate brief familial risk assessment tool. Women with a positive result on the risk assessment tool should receive genetic counseling and, if indicated after counseling, genetic testing. Office Visit: 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99385, 99386, 99387, 99395, 99396, 99397

Genetic Counseling: 96041, S0265

BRCA Lab Screening: 81162, 81163, 81164, 81165, 81166, 81167, 81212, 81215, 81216, 81217

Blood Draw: 36415, 36416 Office Visit and Genetic Counseling:
Z80.0, Z80.3, Z80.41, Z15.01, Z15.02, Z29.81, Z85.3

BRCA Lab Screening:
Z80.0, Z80.3, Z80.41, Z15.01, Z15.02, Z20.6, Z85.3

Blood Draw:
Z80.0, Z80.3, Z80.41, Z15.01, Z15.02 Age 18 years and older

• Normally requires prior authorization.

  Genetic counseling may be required prior to testing.

  Requires a listed diagnosis code for the preventive benefit to apply.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Breast Cancer Screenings Breast Cancer: Medications for Risk Reduction (USPSTF)

Grade: B

Population:
This recommendation applies to asymptomatic women 35 years and older The USPSTF recommends that clinicians offer to prescribe risk-reducing medications, such as tamoxifen, raloxifene, or aromatase inhibitors, to women who are at increased risk for breast cancer and at low risk for adverse medication effects. Office Visit: 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99385, 99386, 99387, 99395, 99396, 99397

Counseling:
99401, 99402, 99403, 99404 Office Visit and Counseling: Z80.3, Z80.41, Z15.01, Z15.02 Age 35 years and older

Please refer to the plan’s pharmacy benefit for details on breast cancer medications available under the plan’s preventive benefit. Prescriptions and counseling are normally considered part of the office visit. If provided outside of an office visit, one of the diagnosis codes listed is required for the preventive benefit to apply.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Colorectal Cancer Screenings Colorectal Cancer Screening (USPSTF)

Grade: B

Population:
Asymptomatic adults 45 to 49 The USPSTF recommends screening for colorectal cancer in adults aged 45 to 49 years.
Screening procedures: Fecal occult blood testing: 82270, 82274, G0328

FIT DNA: 0464U, 81528

Sigmoidoscopy: Screening procedures: Z00.00, Z00.01, Z12.10, Z12.11, Z12.12, Z12.13, Z80.0, Z83.71, Z83.710, Z83.711, Z83.718, Z83.719, Z83.79

Anesthesia:
Z12.11

Age 45 to 75 years

*Some colorectal cancer screenings require prior authorization.

G0105, G0121, 81528, G0328, and S0285 do not require a specific diagnosis.

All other codes require a listed diagnosis

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Colorectal Cancer Screening (USPSTF)

Grade: A

Population:
Asymptomatic adults 50 to 75 The USPSTF recommends screening for colorectal cancer starting at age 50 years and continuing until age 75 years. 45300, 45305, 45308, 45330, 45331, 45333, 45334, 45338, 45341, 45346, 45349, G0104 Colonoscopy: G0105, G0121, 44388, 44389, 44392, 44394, 44401, 44403, 44404, 44406, 45378, 45380, 45381, 45384, 45385, 45388, 45390, 45391 Computed Tomographic Colonoscopy: 74263 Anesthesia: 00812, 99152, 99153, 99156, 99157, G0500
Pathology services: 88304, 88305 Colonoscopy
Pre-Op Consultation: S0285

Pathology services: Z12.11, Z12.12, Z83.710, Z83.711, Z83.718, Z83.719

Colonoscopy Pre-Op Consultation: Z01.818
code for the preventive benefit to apply.

USPSTF recommended intervals for colorectal cancer screening tests are as follows: • High-sensitivity gFOBT or FIT every year • sDNA-FIT every 1 to 3 years • CT colonography every 5 years • Flexible sigmoidoscopy every 5 years • Flexible sigmoidoscopy every 10 years

• FIT every year • Colonoscopy screening every 10 years

  Member cost shares will apply in the following instances:
  • Inappropriate age group • Intervals outside of the USPSTF recommendations • Screenings for diagnostic purposes • Screenings for surveillance purposes • Screenings for therapeutic or treatment purposes

  Please refer to the plan’s pharmacy benefit for details on colorectal bowel preps available under the plan’s pharmacy preventive benefit.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Sexual Health Chlamydia and Gonorrhea Screening (USPSTF)

Grade: B

Population:
Sexually active women ≤24; older women at risk The USPSTF recommends screening for chlamydia in sexually active women aged 24 years or younger and in older women who are at increased risk for infection. The USPSTF also recommends screening for gonorrhea in sexually active women aged 24 years or younger and in older women who are at increased risk for infection. Screening:
86631, 86632, 87110, 87270, 87320, 87490, 87491, 87492, 87801, 87810, 87590, 87591, 87592, 87850

Blood Draw: 36415, 36416 Screening and Blood Draw: Z11.3, Z11.8, Z29.81 Requires a listed diagnosis code for the preventive benefit to apply. Syphilis Infection in Nonpregnant Adolescents and Adults: Screening (USPSTF)

Grade: A

Population:
Asymptomatic, nonpregnant adolescents and adults who are at increased risk for syphilis infection The USPSTF recommends screening for syphilis infection in persons who are at increased risk for infection. Screening: 86592, 86593, 86780

Blood Draw: 36415, 36416 Screening and Blood Draw: Z11.2, Z11.3, Z11.8, Z29.81 Requires a listed diagnosis code for the preventive benefit to apply.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Sexual Health HIV Infection Screening (USPSTF and Bright Futures)

Grade: A

Population:
Adolescents and adults aged 15 to 65 years The USPSTF recommends that clinicians screen for HIV infection in adolescents and adults aged 15 to 65 years. Younger adolescents and older adults who are at increased risk of infection should also be screened. Screening: 80081, 86689, 86701, 86702, 86703, 87389, 87390, 87391, 87534, 87535, 87536, 87537, 87538, 87539, 87806, G0432, G0433, G0435, G0475, S3645

Blood Draw: 36415, 36416 Screening and Blood Draw: Z11.3, Z11.4, Z11.59, Z29.81 Requires a listed diagnosis code for the preventive benefit to apply.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Sexual Health Preexposure Prophylaxis for HIV Prevention (USPSTF)

Grade: A

Population:
Persons, including adolescents, who are not infected with HIV and are at high risk of HIV infection The USPSTF recommends that clinicians offer preexposure prophylaxis (PrEP) with effective antiretroviral therapy to persons who are at high risk of HIV acquisition. Injection Administration: 96372

Injection/Oral Med: G0012, J0738, J0739, J0750, J0751, J0752, J0799

Kidney Testing: 82565, 82575

Pregnancy Testing: 81025

Office Visit: 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215,G0011, G0013

Pharmacy supplying fee for HIV PrEP: Q0521 All PrEP Services: Z11.3, Z11.4, Z20.2, Z20.6, Z29.81, Z72.51, Z72.52, Z72.53 Prior authorization requirements may apply. Prescription required for PrEP injections and/or medications. Please refer to the plan's pharmacy benefit for details on HIV Pre-Exposure Prophylaxis option(s) available under the plan's pharmacy preventive benefit. Requires a listed diagnosis code for the preventive benefit to apply.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Sexual Health Cervical Cancer Screening: human papillomavirus Testing (USPSTF and WPSI)

Grade: A

Population:
This recommendation statement applies to all asymptomatic women with a cervix, regardless of their sexual history.
The USPSTF recommends screening for cervical cancer every 3 years with cervical cytology alone in women aged 21 to 29 years. For women aged 30 to 65 years, the USPSTF recommends screening every 3 years with cervical cytology alone, every 5 years with high-risk human papillomavirus (hrHPV) testing alone, or every 5 years with hrHPV testing in combination with cytology (cotesting). Collection: Q0091

Laboratory Testing (PAP Test): 88141, 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88155, 88164, 88165, 88166, 88167, 88174, 88175, G0101, G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001

Human Papillomavirus DNA Testing (HPV): 87623, 87624, 87625, 87626, G0476 Z01.411, Z01.419, Z11.51, Z12.4, Z12.72
Age 21 through 65 years

Requires a listed diagnosis code for the preventive benefit to apply.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Contraceptives Contraceptive Services and Counseling (USPSTF and WPSI)

Grade: A

Population:
This recommendation statement applies to all asymptomatic women with a cervix, regardless of their sexual history. The Women’s Preventive Services Initiative (WPSI) recommends that adolescent and adult women have access to the full range of contraceptives and contraceptive care to prevent unintended pregnancies and improve health outcomes. Contraceptive care includes screening, education, counseling, and provision of contraceptives. Contraceptive care also includes follow-up care (for example, management, evaluation, and changes, including the removal, continuation, and discontinuation of contraceptives).

The full range of contraceptives includes those currently listed in the FDA's Birth Control Guide:

1. Sterilization surgery for women
2. Implantable rods

3. Copper intrauterine devices Sterilizations: Hysteroscopy: 58565

   Minilaparotomy or Laparotomy: 58600, 58605, 58611, 58615

   Laparoscopy: 58661, 58670, 58671

   Tubal Ligation Follow- Up: 58340, 74740, Q9967

   Implantable: 11981, 11982, 11983, 11976

   Sterilizations: Z30.2

   Tubal Ligation Follow- Up: Z98.51, Z30.40, Z30.49, Z98.51

   Implantables:
   Z30.017, Z30.46

   Copper/Hormonal IUDs:
   Z30.014, Z30.430, Z30.431, Z30.432, Z30.433

   Diaphragms/Cervical Caps:
   Z30.018

   Wellness examination codes include counseling for contraceptive services and are thus not separately reimbursable when performed as part of a wellness examination.

   Counseling and contraceptive services require a listed diagnosis code for the preventive benefit to apply if provided outside of a preventive visit.

   The listed diagnosis code is requested but not required for the preventive benefit to apply to the following codes: 58600, 58605, 58611,

4. Other services require a listed diagnosis code for the preventive benefit to apply.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Contraceptives

4. Intrauterine devices with progestin (all durations and doses)
5. Injectable contraceptives
6. Oral contraceptives (combined pill)
7. Oral contraceptives (progestin only)
8. Oral contraceptives (extended or continuous use)
9. The contraceptive patch
10. Vaginal contraceptive rings
11. Diaphragms
12. Contraceptive sponges
13. Cervical caps
14. Condoms
15. Spermicides
16. Emergency contraception (levonorgestrel)
17. Emergency contraception (ulipristal acetate)

18. And any additional contraceptives approved, granted, or cleared by the FDA. Copper/Hormonal IUDs:
    58300, 58301

    Diaphragms/Cervical Caps:
    57170

    Injections/Supply Codes:
    J1050, J7296, J7297, J7298, J7300, J7301, J7303, J7304, J7306, J7307, A4261, A4264, A4266, S4981, S4989

    Contraceptive Shot Administration:
    96372

    Office Visits for Contraceptive Services:
    99384, 99385, 99386, 99394, 99395, 99396, Injections/Supply Codes: Z30.013, Z30.42, Z30.011, Z30.41

    Contraceptive Shot Administration:
    Z30.013, Z30.42, Z30.011, Z30.41

    Office Visits for Contraceptive or Sterilization: Z30.011, Z30.019, Z30.02, Z30.09, Z30.015, Z30.016, Z30.40 , Z30.41, Z30.44, Z30.45, Z30.49, Z30.018, Z30.012, Z30.8, Z30.9

    IUD Follow-up Visit: Z30.431

    Please note that code 96372 should not be reported if service was provided without direct physician or other qualified healthcare professional supervision. In this case, report code 99211 (Office or other outpatient visit for the evaluation and management of an established patient) instead of 96372.

    J1050 should be used for Depo-Provera injections.

    Refer to the plan’s pharmacy benefit plan administrator for details on contraceptives available under the plan’s pharmacy preventive benefit.

    Natural Cycles: Annual Subscription — Member submitted claim billed with CPT code A9293 and

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Contraceptives 99401, 99402, 99403, 99404, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215

IUD Follow-up Visit: 99211, 99212

IUD Ultrasound: 76830, 76857

Anesthesia:
00840, 00851, 00940, 00952

Pregnancy Testing: 81025
IUD Ultrasound: Z30.430, Z30.431, Z30.432, Z30.433

Anesthesia:
Z30.2

Pregnancy Testing: Z30.012, Z30.013, Z30.014, Z30.017, Z30.018, Z30.019, Z30.09, Z30.40, Z30.42, Z30.430, Z30.431, Z30.432, Z30.433, Z30.46, Z30.49, Z30.8, Z30.9 diagnosis code Z30.8 and/or Z30.9.

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Pregnancy Pregnancy Diagnosis Code Listing:
O09.00 O09.01 O09.02 O09.03 O09.10 O09.11 O09.12 O09.13 O09.211 O09.212 O09.213 O09.219 O09.291 O09.292 O09.293 O09.299 O09.30 O09.31 O09.32 O09.33 O09.40 O09.41 O09.42 O09.43 O09.511 O09.512 O09.513 O09.519 O09.521 O09.522 O09.523 O09.529 O09.611 O09.612 O09.613 O09.619 O09.621 O09.622 O09.623 O09.629 O09.70 O09.71 O09.72 O09.73 O09.811 O09.812 O09.813 O09.819 O09.821 O09.822 O09.823 O09.829 O09.891 O09.892 O09.893 O09.899 O09.90 O09.91 O09.92 O09.93 O09.A0 O09.A1 O09.A2 O09.A3 O30.001 O30.002 O30.003 O30.009 O30.011 O30.012 O30.013 O30.019 O30.021 O30.022 O30.023 O30.029 O30.031 O30.032 O30.033 O30.039 O30.041 O30.042 O30.043 O30.049 O30.091 O30.092 O30.093 O30.099 O30.101 O30.102 O30.103 O30.109 O30.111 O30.112 O30.113 O30.119 O30.121 O30.122 O30.123 O30.129 O30.131 O30.132 O30.133 O30.139 O30.231 O30.232 O30.233 O30.239 O30.831 O30.832 O30.833 O30.839 O30.191 O30.192 O30.193 O30.199 O30.201 O30.202 O30.203 O30.209 O30.211 O30.212 O30.213 O30.219 O30.221 O30.222 O30.223 O30.229 O30.291 O30.292 O30.293 O30.299 O30.801 O30.802 O30.803 O30.809 O30.811 O30.812 O30.813 O30.819 O30.821 O30.822 O30.823 O30.829 O30.891 O30.892 O30.893 O30.899 O30.90 O30.91 O30.92 O30.93 O36.80X0 O36.80X1 O36.80X2 O36.80X3 O36.80X4 O36.80X5 O36.80X9 Z33.1 Z34.00 Z34.01 Z34.02 Z34.03 Z34.80 Z34.81 Z34.82 Z34.83 Z34.90 Z34.91 Z34.92 Z34.93

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Pregnancy Folic Acid Supplements to Prevent Neural Tube Defects (USPSTF)

Grade: A

Population:
Pregnant women The USPSTF recommends that all women who are planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid.

Part of the pharmacy benefit.

Please refer to the plan's pharmacy benefit for details on folic acid options available under the plan's pharmacy preventive benefit.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Pregnancy Gestational Diabetes: Screening (USPSTF and WPSI)

Grade: B

Population:
Pregnant women The USPSTF recommends screening for gestational diabetes mellitus in asymptomatic pregnant women after 24 weeks of gestation.

WPSI recommends screening pregnant women for gestational diabetes mellitus after 24 weeks of gestation (preferably between 24 and 28 weeks of gestation) to prevent adverse birth outcomes. WPSI recommends screening pregnant women with risk factors for type 2 diabetes or GDM before 24 weeks of gestation — ideally at the first prenatal visit. Screening:
82947, 82948, 82950, 82951, 82952, 83036, 83037

Blood Draw: 36415, 36416 Screening:
Z13.1

See the Pregnancy Diagnosis Code Listing

Blood Draw:
Z13.1 Age 12 through 49 years

Requires a listed diagnosis code as well as a diagnosis from the pregnancy diagnosis listing for the preventive benefit to apply. Screening for Diabetes Mellitus After Pregnancy (WPSI)

Grade: N/A

Population: Postpartum women The Women’s Preventive Services Initiative recommends women with a history of gestational diabetes mellitus (GDM) who are not currently pregnant and who have not previously been diagnosed with type 2 diabetes mellitus should be screened for diabetes mellitus. Initial testing should ideally occur within the first year postpartum and can be conducted as early as 4–6 weeks postpartum. Screening:
82947, 83036, 83037

Blood Draw:
36415, 36416 Screening and Blood Draw: Z13.1, Z86.32 Age 12 through 49 years

Requires a listed diagnosis code for the preventive benefit to apply. If a diabetes diagnosis code is present in any position, the preventive benefit will not be applied.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Pregnancy Depression Screening (USPSTF)

Grade:

Population:
Pregnant women The USPSTF recommends screening for depression in the general adult population, including pregnant and postpartum women. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. 96127, 96160, G0444 Z13.31, Z13.32
Age 12 through 49 years

Requires a listed diagnosis code for the preventive benefit to apply. Perinatal Depression: Preventive Interventions (USPSTF)

Grade: B

Population:
Pregnant and postpartum women The USPSTF recommends that clinicians provide or refer pregnant and postpartum persons who are at increased risk of perinatal depression to counseling interventions. 96127, 96156, 96158, 96159, 96160, 96161, 96164, 96165, 96167, 96168, G0444 Z13.31, Z13.32, Z39.2 Age 12 through 49 years

Requires a listed diagnosis code for the preventive benefit to apply.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Pregnancy Asymptomatic Bacteriuria in Adults: Screening (USPSTF)

Grade: B

Population:
Pregnant women The USPSTF recommends screening for asymptomatic bacteriuria with urine culture in pregnant women at 12 to 16 weeks’ gestation or at the first prenatal visit. 81007, 87081, 87084, 87086, 87088 See the Pregnancy Diagnosis Code Listing Age 12 through 49 years

Requires a listed diagnosis code from the pregnancy diagnosis listing for the preventive benefit to apply.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Pregnancy Healthy Weight and Weight Gain in Pregnancy: Behavioral Counseling Interventions (USPSTF)

Grade: B

Population:
For pregnant adolescents and all adults The USPSTF recommends that clinicians offer pregnant persons effective behavioral counseling interventions aimed at promoting healthy weight gain and preventing excess gestational weight gain in pregnancy. Medical Nutrition Therapy: 97802, 97803, 97804, G0270, G0271, S9470

Preventive Medicine Individual Counseling: 99401, 99402, 99403, 99404

Behavioral Counseling or Therapy: G0447, G0473
See the Pregnancy Diagnosis Code Listing Age 12 through 49 years

Requires a listed diagnosis code from the pregnancy diagnosis listing for the preventive benefit to apply.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Pregnancy Hepatitis B Virus Infection in Pregnant Women: Screening (USPSTF)

Grade: A

Population:
Pregnant women The USPSTF recommends screening for hepatitis B virus (HBV) infection in pregnant women at their first prenatal visit. Screening:
80055, 80081, 87340, 87341, 87467

Blood Draw: 36415, 36416 Screening and Blood Draw: Z11.59, Z20.5 Age 12 through 49 years

Requires a listed diagnosis code from the pregnancy diagnosis listing for the preventive benefit to apply. Preeclampsia Screening and Preventive Medicine (USPSTF)

Grade: B

Population:
Pregnant women The USPSTF recommends screening for preeclampsia in pregnant women with blood pressure measurements throughout pregnancy.

Typically part of prenatal care visit

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Pregnancy Rh(D) Incompatibility: Screening — First pregnancy-related care visit (USPSTF)

Grade: A

Population:
Pregnant women The USPSTF strongly recommends Rh(D) blood typing and antibody testing for all pregnant women during their first visit for pregnancy-related care.
Screening:
80055, 80081, 86850, 86901

Blood Draw: 36415, 36416 Screening: See the Pregnancy Diagnosis Code Listing

Blood Draw: Z01.83 Age 12 through 49 years

Requires a listed diagnosis code from the pregnancy diagnosis listing for the preventive benefit to apply. Rh(D) Incompatibility: Screening — Unsensitized Rh(D)- negative women (USPSTF)

Grade: B

Population:
Pregnant women The USPSTF also recommends repeated Rh(D) antibody testing for all unsensitized Rh (D)- negative women at 24 to 28 weeks’ gestation, unless the biological father is known to be Rh(D)-negative. Screening:
80055, 80081, 86850, 86901

Blood Draw:
36415, 36416 Screening: See the Pregnancy Diagnosis Code Listing

Blood Draw: Z01.83 Age 12 through 49 years

Requires a listed diagnosis code from the pregnancy diagnosis listing for the preventive benefit to apply.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Pregnancy Aspirin Use to Prevent Preeclampsia and Related Morbidity and Mortality: Preventive Medication (USPSTF)

Grade: B

Population:
Pregnant persons at high risk for preeclampsia The USPSTF recommends the use of low-dose aspirin (81 mg/day) as preventive medication after 12 weeks of gestation in persons who are at high risk for preeclampsia.

Part of the pharmacy benefit. Please refer to the plan’s pharmacy benefit for details on aspirin options available under the plan’s pharmacy preventive benefit. Human Immunodeficiency Virus Infection: Screening (USPSTF)

Grade: A

Population:
Pregnant women The USPSTF recommends that clinicians screen for HIV infection in all pregnant persons, including those who present in labor or at delivery whose HIV status is unknown. Screening:
80081, 86689, 86701, 86702, 86703, 87389, 87390, 87391, 87534, 87535, 87536, 87537, 87538, 87539, 87806, G0432, G0433, G0435, G0475, S3645

Blood Draw: 36415, 36416 Screening and Blood Draw:
Z11.3, Z11.4, Z11.59, Z20.2, Z20.6, Z72.51, Z72.52, Z72.53 Age 12 through 49 years

Requires a listed diagnosis code for the preventive benefit to apply.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Pregnancy Syphilis Infection in Pregnant Women: Screening (USPSTF)

Grade: A

Population:
Pregnant women The USPSTF recommends early screening for syphilis infection in all pregnant women. Screening: 80055, 80081, 86592, 86593, 86780

Blood Draw: 36415, 36416 Screening and Blood Draw:
Z11.2, Z11.3, Z11.8, Z20.2, Z72.51, Z72.52, Z72.53 Age 12 through 49 years

Requires a listed diagnosis code for the preventive benefit to apply

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Breastfeeding Breastfeeding Services and Supplies (WPSI)

Grade: N/A

Population: Pregnant and postpartum women The Women's Preventive Services Initiative recommends comprehensive lactation support services (including consultation, counseling, education by clinicians, and peer support services; and breastfeeding equipment and supplies) during the antenatal, perinatal, and postpartum periods to optimize the successful initiation and maintenance of breastfeeding. Counseling:
99401, 99402, 99403, 99404, 99411, 99412, 98960, 98961, 98962

Lactation Classes: S9443

Breast Pumps: E0602, E0603

Replacement Parts: A4281, A4282, A4283, A4284, A4285, A4286, A4288

Storage Bags: A4287 Counseling and Lactation Classes: Z39.1

Breast Pumps and Replacement Parts: See the Pregnancy Diagnosis Code Listing

Other Diagnosis:
Z39.1
Counseling is normally considered part of wellness office visit.

Requires a listed diagnosis code for the preventive benefit to apply if counseling is provided outside of a preventive visit.

All other services, durable medical equipment, and replacement parts require an appropriate diagnosis code from the appropriate group or other diagnosis group for the preventive benefit to apply.

Breastfeeding equipment and supplies include, but are not limited to, double electric breast pumps, pump parts and maintenance, and breast milk storage supplies. Breastfeeding equipment may also include equipment and supplies as clinically indicated to support dyads with breastfeeding difficulties.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Breastfeeding Breastfeeding: Primary Care Behavioral Counseling Interventions (USPSTF)

Grade: B

Population: Pregnant and postpartum women The USPSTF recommends providing interventions during pregnancy and after birth to support breastfeeding. 99401, 99402, 99403, 99404, 99411, 99412, S9443 Z39.1, Z39.2 Counseling is normally considered part of a wellness office visit.

Requires a listed diagnosis code for the preventive benefit to apply if counseling is provided outside of a preventive visit.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Newborn Care Bilirubin concentration screening (Bright Futures)

Grade: N/A

Population: Newborns (0 to 90 days) The HSRA recommends screening for bilirubin concentration in newborns. Screening: 82247, 88720

Blood Draw:
36415, 36416 Screening and Blood Draw: Z13.228 Age 0 to 90 days

Requires a listed diagnosis code for the preventive benefit to apply. Newborn Metabolic Screening Panel
(Bright Futures)

Grade: N/A

Population: Newborns (0 to 90 days) The HSRA recommends blood screening in newborns. Screening:
S3620

Blood Draw:
36415, 36416 Screening and Blood Draw: Z13.0, Z13.21, Z13.228, Z13.29 Age 0 to 90 days

Typically included as part of delivery.

Requires a listed diagnosis code for the preventive benefit to apply if performed separately.

Conduct screening as required by state-specific newborn screening requirements.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Newborn Care Hematocrit or hemoglobin screening (Bright Futures)

Grade: N/A

Population: Newborns (0 to 90 days) The HSRA recommends screening for sickle cell disease in newborns. Screening: 83020, 83021, S3620

Blood Draw:
36415, 36416 Screening and Blood Draw: Z13.0, Z13.21, Z13.228, Z13.29 Age 0 to 90 days

Typically included as part of delivery.

Requires a listed diagnosis code for the preventive benefit to apply if performed separately. Hypothyroidism screening (Bright Futures)

Grade: N/A

Population: Newborns (0 to 90 days) The HSRA recommends screening for congenital hypothyroidism in newborns. Screening: 84437, 84443, S3620

Blood Draw:
36415, 36416 Screening and Blood Draw: Z13.0, Z13.21, Z13.228, Z13.29 Age 0 to 90 days

Typically included as part of delivery.

Requires a listed diagnosis code for the preventive benefit to apply if performed separately.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Newborn Care Ocular Prophylaxis for Gonococcal Ophthalmia Neonatorum: Preventive Medication (USPSTF)

Grade: A

Population: Newborns (0 to 90 days) The USPSTF recommends prophylactic ocular topical medication for all newborns to prevent gonococcal ophthalmia neonatorum.

Included as part of delivery. Phenylketonuria screening (USPSTF)

Grade:

Population: Newborns (0 to 90 days) The USPSTF recommends screening for phenylketonuria in newborns. Screening: S3620, 84030

Blood Draw:
36415, 36416 Screening and Blood Draw: Z13.0, Z13.21, Z13.228, Z13.29 Age 0 to 90 days

Typically included as part of delivery.

Requires a listed diagnosis code for the preventive benefit to apply if performed separately.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Child Screenings Anemia Screening in Children (Bright Futures)

Grade: N/A

Population:
Children at 12 months and all children at risk Bright Futures recommends anemia screening at 12 months, with additional screenings recommended periodically for patients determined to be at risk. Screening:
85014, 85018

Blood Draw:
36415, 36416 Screening and Blood Draw: Z13.0 Age 1 year

Requires a listed diagnosis code for the preventive benefit to apply. Hearing screening newborns and regular screenings (Bright Futures)

Grade: N/A

Population:
All children Bright Futures recommends hearing tests at ages: Newborn; Between 3-5 days to 2 months; 4 years; 5 years, 6 years; 8 years; 10 years; Once between age 11 and 14 years; Once between age 15 and 17 years; Once between age 18 and 21 years; Also recommended for those who have a positive risk assessment. 92551, 92552, 92558, 92567, 92587, 92588, 92650, 92651, V5008
Z00.121, Z00.129, Z00.110, Z00.111, Z01.10, Z01.110, Z01.118, P09.6 Age 0 through 21 years

Requires a listed diagnosis code for the preventive benefit to apply.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Child Screenings Dyslipidemia screening (Bright Futures)

Grade: N/A

Population: All children Bright Futures recommends dyslipidemia screening as follows: Once between age 9 and 11 years; once between age 17 and 21 years; or if a risk assessment is positive. Screening:
80061, 82465, 83718, 83719, 83721, 83722, 84478

Blood Draw:
36415, 36416 Screening and Blood Draw: Z13.220 Age 2 through 21 years

Requires a listed diagnosis code for the preventive benefit to apply. Lead screening (Bright Futures)

Grade: N/A

Population:
Children at risk Bright Futures recommends lead screening at the following intervals: 12 months and 24 months, or if a risk assessment is positive. Screening:
83655

Blood Draw:
36415, 36416 Screening: Z00.121, Z00.129, Z77.011, Z13.88

Blood Draw: Z13.88 Age 6 months through 6 years

Requires a listed diagnosis code for the preventive benefit to apply.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Child Screenings Alcohol, tobacco, and drug use assessments (USPSTF and Bright Futures)

Grade: B

Population:
School-aged children and adolescents who have not started to use tobacco younger than 18 years
The USPSTF recommends that primary care clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use among school-aged children and adolescents. Bright Futures recommends that Adolescents be assessed for use of Tobacco, Alcohol, or Drug use beginning at the age of 11 years old. 99406, 99407, 99408, 99409, G0396, G0397, G0442, G2011 F10.10, F11.10, F12.10, F13.10, F15.90, F16.90, F17.290, Z13.39, Z71.41, Z71.51, Z71.6, Z87.891 Age 11 through 21 years

Requires a listed diagnosis code for the preventive benefit to apply.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Child Screenings Depression and Suicide Risk in Children and Adolescents: Screening (USPSTF and Bright Futures)

Grade: B

Population: Adolescents The USPSTF recommends screening for major depressive disorder (MDD) in adolescents aged 12 to 18 years.

Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. 96127, 96160, G0444 Z13.31, Z13.32 Age 12 through 18 years

Requires a listed diagnosis code for the preventive benefit to apply. Developmental screening (Bright Futures)

Grade: N/A

Population:
Children under 3 Bright Futures recommends a formal, standardized developmental screen during the 9-month visit. A formal, standardized developmental screen is recommended during the 18-month visit, including a formal autism screen. A formal, standardized autism screen is recommended during the 24-month visit. A formal, standardized developmental screen is recommended during the 30-month visit. 96110, G0451 Z13.40, Z13.41, Z13.42, Z13.49 Age 9 months through 2 years

Requires a listed diagnosis code for the preventive benefit to apply.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Child Screenings High Body Mass Index in Children and Adolescents: Interventions (USPSTF)

Grade: B

Population:
Children and adolescents 6 years or older with a high body mass index (BMI) (≥95th percentile for age and sex) The USPSTF recommends that clinicians provide or refer children and adolescents 6 years or older with a high body mass index (BMI) (≥ 95th percentile for age and sex) to comprehensive, intensive behavioral interventions. Medical Nutrition Therapy: 97802, 97803, 97804, G0270, G0271, S9470

Preventive Medicine Individual Counseling: 99401, 99402, 99403, 99404

Behavioral Counseling or Therapy: 0403T, G0446, G0447, G0473 Primary Diagnosis Codes:
Z71.3, Z72.4, Z72.3

Secondary Diagnosis Codes:
Body Mass Index 30.0-39.9: Z68.30, Z68.31, Z68.32, Z68.33, Z68.34, Z68.35, Z68.36, Z68.37, Z68.38, Z68.39

Body Mass Index 40.0 and over: Z68.41, Z68.42, Z68.43, Z68.44, Z68.45

Obesity:
E66.01, E66.09, E66.1, E66.8, E66.9, Z68.54 Age 6 through 18 years

Counseling is normally considered part of a wellness office visit.

Requires a listed diagnosis code for the preventive benefit to apply if provided outside of a preventive visit.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Child Screenings Autism screening (Bright Futures)

Grade: N/A

Population:
Children at 18 and 24 months Bright Futures recommends a formal, standardized developmental screen during the 18-month visit and during the 24-month visit. 96110, 96127 Z13.41 Age 1 through 2 years

Requires a listed diagnosis code for the preventive benefit to apply. Prevention of Dental Caries in Children Younger Than 5 Years: Screening and Interventions — Fluoride Supplements (USPSTF and Bright Futures)

Grade: B

Population: Asymptomatic children younger than 5 years The USPSTF recommends primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is fluoride-deficient.

Age 5 years and younger

Please refer to the plan's pharmacy benefit for details on fluoride supplements available under the plan's pharmacy preventive benefit.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Child Screenings Prevention of Dental Caries in Children Younger Than 5 Years: Screening and Interventions — Fluoride Varnish (USPSTF and Bright Futures)

Grade: B

Population:
Children younger than 5 years The USPSTF recommends the application of fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption until age 5 in primary care practices. 99188 Z00.121, Z00.129, Z29.3, Z91.841, Z91.842, Z91.843, Z91.849 Age 5 years and younger

Requires a listed diagnosis code for the preventive benefit to apply.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Child Screenings Vision in Children Ages 3 to 5 Years: Screening (USPSTF and Bright Futures)

Grade: B

Population:
Children Ages 3 to 5 Years The USPSTF recommends vision screening at least once in all children ages 3 to 5 years to detect amblyopia or its risk factors.

Bright Futures recommends periodic vision screenings through age 21. 99173, 99174, 99177 Z01.020, Z01.021, Z00.121, Z00.129 Age 3 through 21 years

Requires a listed diagnosis code for the preventive benefit to apply.
Hepatitis B screening (USPSTF and Bright Futures)

Grade: B

Population: Adolescents at increased risk for infection The USPSTF recommends screening for hepatitis B virus (HBV) infection in adolescents and adults at increased risk for infection. Screening:
86704, 86705, 86706, 86707, 87340, 87341, G0499

Blood Draw:
36415, 36416 Screening and Blood Draw: Z11.59, Z20.5 Age 12 through 18 years

Requires a listed diagnosis code for the preventive benefit to apply.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Child Screenings Tuberculosis (TB) Testing (Bright Futures)

Population:
Children infected with human immunodeficiency virus (HIV) Bright Futures recommends an annual tuberculosis test for children infected with human immunodeficiency virus (HIV).
Screening: 86580

Follow-Up Visit: 99211
Screening:
Z11.1

Follow-up Visit:
Z11.1 Requires a listed diagnosis code for the preventive benefit to apply.

NOTE: There is no separate administration code for the PPD test. Do not report one. Sudden Cardiac Arrest (Bright Futures)

Population:
Children ages 11 to 21 years Bright Futures recommends that all children be evaluated for conditions predisposing to SCA and SCD in the course of routine healthcare. A thorough and detailed history, family history, and physical examination are necessary to begin assessing SCA and SCD risk. The ECG should be the first test ordered when there is a concern for SCA risk. The ECG should be interpreted by a physician trained in recognizing electrical heart disease (in other words, a pediatric cardiologist or pediatric electrophysiologist). 96160, 96161 Z13.6 Requires a listed diagnosis code for the preventive benefit to apply.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Adult Screenings Abdominal Aortic Aneurysm Screening (USPSTF)

Grade: B

Population: Men aged 65 to 75 years who have ever smoked The USPSTF recommends one- time screening for abdominal aortic aneurysm by ultrasonography in men aged 65 to 75 years who have ever smoked. 76706 F17.210, F17.211, F17.213, F17.218, F17.219, Z13.6, Z87.891
Age 65 through 75 years

Requires a listed diagnosis code for the preventive benefit to apply.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Adult Screenings Cervical Cancer Screening: Pap testing
(USPSTF and WPSI)

Grade: A

Population: This recommendation statement applies to all asymptomatic women with a cervix, regardless of their sexual history.
The USPSTF and WPSI recommend screening for cervical cancer every 3 years with cervical cytology alone in women aged 21 to 29 years. For women aged 30 to 65 years, the USPSTF recommends screening every 3 years with cervical cytology alone, every 5 years with high-risk human papillomavirus (hrHPV) testing alone, or every 5 years with hrHPV testing in combination with cytology (cotesting). Wellness Visit:
99385, 99386, 99395, 99396, G0101

Collection: Q0091

Laboratory Testing: 88141, 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88155, 88164, 88165, 88166, 88167, 88174, 88175, G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001 Wellness Visit: Z00.00, Z00.01, Z01.411, Z01.419, Z12.31, Z12.4, Z12.72

Collection and Laboratory Testing: Z01.411, Z01.419, Z12.4, Z12.72 Age 21 through 65 years

Wellness visits do not require a diagnosis for the preventive benefit to apply.

Collection and testing services require a listed diagnosis code for the preventive benefit to apply.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Adult Screenings Lung Cancer: Screening (USPSTF)

Grade: B

Population: Adults aged 50 to 80 years who have a 20 pack- year smoking history and currently smoke or have quit within the past 15 years The USPSTF recommends annual screening for lung cancer with low- dose computed tomography (LDCT) in adults aged 50 to 80 years who have a 20-pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery. 71271, G0296 Z71.6, F17.200, F17.210, F17.211, F17.213, F17.218, F17.219, F17.220, F17.290, Z87.891 Age 50 through 80 years

*Normally requires a prior authorization

Requires a listed diagnosis code for the preventive benefit to apply.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Adult Screenings Osteoporosis to Prevent Fractures: Screening (USPSTF)

Grade: B

Population: Women 65 years and older and postmenopausal women younger than 65 years at increased risk without a history of low-trauma fractures and without conditions that may cause secondary osteoporosis. 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 also recommends screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in women 65 years and older. Age 65 and older:
77080, 77081, 77085

High Risk: 77081, 77085, G0130 Age 65 and older: Z13.820

High Risk:
Z78.0, Z79.890, Z82.62 Age 65 years and older unless at increased risk

Requires a listed diagnosis code for the preventive benefit to apply.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Adult Screenings Prediabetes and Type 2 Diabetes Screening (USPSTF)

Grade: B

Population: Asymptomatic nonpregnant adults aged 35 to 70 years who are overweight or obese The USPSTF recommends screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged 35 to 70 years who are overweight or obese. Clinicians should offer or refer patients with abnormal blood glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity.

Screening Interval: USPSTF's recommended interval for screening is once every 3 years. 82947, 83036 Z13.1, R73.03, R73.09 Age 35 through 70 years

Requires a listed diagnosis code for the preventive benefit to apply.

Please see the section labeled Weight Loss to Prevent Obesity Related Morbidity and Mortality in Adults: Behavioral Interventions for applicable interventions to promote a healthful diet and physical activity.

Please refer to the plan's pharmacy benefit for details on prediabetes options available under the plan's pharmacy preventive benefit.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Adult Screenings Unhealthy Alcohol Use in Adolescents and Adults: Screening and Behavioral Counseling Interventions (USPSTF)

Grade: B

Population: Adults 18+, including pregnant women The USPSTF recommends screening for unhealthy alcohol use in primary care settings in adults 18 years or older, including pregnant women, and providing persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce unhealthy alcohol use. 99408, 99409, G0442, G0443 F10.10, Z71.41 Age 18 years and older

Requires a listed diagnosis code for the preventive benefit to apply. Depression and Suicide Risk in Adults: Screening (USPSTF)

Grade: B

Population: All adults The USPSTF recommends screening for depression in the adult population, including pregnant and postpartum persons, as well as older adults. 96127, G0444 Z13.31 Age 18 years and older

Requires a listed diagnosis code for the preventive benefit to apply.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Adult Screenings Tobacco Smoking Cessation in Adults, Including Pregnant Persons: Interventions (USPSTF)

Grade: A

Population: All adults The USPSTF recommends that clinicians ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and United States Food and Drug Administration (FDA)–approved pharmacotherapy for cessation to adults who use tobacco. 99406, 99407 Z71.6, F17.200, F17.210, F17.211, F17.213, F17.218, F17.219, F17.220, F17.290, Z87.891 Age 18 years and older

Requires a listed diagnosis code for the preventive benefit to apply.

Please refer to the plan's pharmacy benefit for details on smoking cessation options available under the plan's pharmacy preventive benefit. Unhealthy Drug Use Screening (USPSTF)

Grade: B

Population: Adults aged 18 years or older The USPSTF recommends screening by asking questions about unhealthy drug use in adults aged 18 years or older. Screening should be implemented when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred.
99408, 99409, G0396, G0397, G0442, G0443, G2011 F11.10, F12.10, F13.10, F13.90, F15.90, F16.90, Z71.51, Z91.89
Age 18 years and older

Requires a listed diagnosis code for the preventive benefit to apply.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Adult Screenings Weight Loss to Prevent Obesity Related Morbidity and Mortality in Adults: Behavioral Interventions (USPSTF)

Grade: B

Population: Adults with body mass index Greater Than or Equal to 30 The USPSTF recommends that clinicians offer or refer adults with a body mass index (BMI) of 30 or higher to intensive, multicomponent behavioral interventions. Medical Nutrition Therapy: 97802, 97803, 97804, G0270, G0271, S9470

Preventive Medicine Individual Counseling: 99401, 99402, 99403, 99404

Behavioral Counseling or Therapy: 0403T, G0446, G0447, G0473 Primary Diagnosis Codes:
Z71.3, Z72.4, Z72.3

Secondary Diagnosis Codes:
Body Mass Index 30.0-39.9: Z68.30, Z68.31, Z68.32, Z68.33, Z68.34, Z68.35, Z68.36, Z68.37, Z68.38, Z68.39

Body Mass Index 40.0 and over: Z68.41, Z68.42, Z68.43, Z68.44, Z68.45

Obesity:
E66.01, E66.09, E66.1, E66.8, E66.9 Counseling is normally considered part of a wellness office visit.

Requires a listed diagnosis code for the preventive benefit to apply if provided outside of a preventive visit.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Adult Screenings Hepatitis B Infection Screening (USPSTF)

Grade: B

Population: Adults at increased risk for infection The USPSTF recommends screening for hepatitis B virus (HBV) infection in adolescents and adults at increased risk for infection. Screening:
86704, 86705, 86706, 86707, 87340, 87341, G0499

Blood Draw:
36415, 36416 Screening and Blood Draw: Z11.59, Z20.5 Age 18 years and older

Requires a listed diagnosis code for the preventive benefit to apply. Hepatitis C Infection Screening (USPSTF)

Grade: B

Population: Adults aged 18 to 79 years The USPSTF recommends screening for hepatitis C virus (HCV) infection in adults aged 18 to 79 years.

Bright Futures recommends screening all individuals ages 18 to 79 years at least once for hepatitis C virus infection (HCV). Screening:
86803, 86804, G0472

Blood Draw:
36415, 36416 For one-time Screening and Blood Draw: Z11.59

For repeat Screening and Blood Draw:
Z72.89, F19.20 Age 18 through 79 years

Requires a listed diagnosis code for the preventive benefit to apply.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Adult Screenings Latent Tuberculosis Infection in Adults: Screening (USPSTF)

Grade: B

Population: Asymptomatic adults at increased risk of latent tuberculosis infection (LTBI) The USPSTF recommends screening for LTBI in populations at increased risk.
Screening:
86480, 86481, 86580

Blood Draw:
36415, 36416

Follow-Up Visit: 99211 Screening and Blood Draw: Z11.7

Follow-Up Visit: R76.11, R76.12 Age 18 years and older

Requires a listed diagnosis code for the preventive benefit to apply.

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Preventive service Description Procedure code(s) Diagnosis code(s) Instructions Health Promotion Falls Prevention in Community-Dwelling Older Adults: Interventions (USPSTF)

Grade: B

Population: Adults 65 years or older The USPSTF recommends exercise interventions to prevent falls in community-dwelling adults 65 years or older who are at increased risk for falls. 97110, 97112, 97116, 97161, 97162, 97163, 97530, 97750, G0151, G0157, G0159, G2168, G2169, S9131 Z91.81 Age 65 years and older

Requires a listed diagnosis code for the preventive benefit to apply. Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: Prevention Medication (USPSTF)

Grade: B

Population: Adults 40– 75 The USPSTF recommends that clinicians prescribe a statin for the primary prevention of cardiovascular disease (CVD) for adults aged 40 to 75 years who have one or more CVD risk factors (in other words, dyslipidemia, diabetes, hypertension, or smoking) and an estimated 10-year risk of a cardiovascular event of 10% or greater. Screening:
80061, 82465, 83718, 83719, 83721, 83722, 84478

ASCVD Risk Assessment and Risk Management Services: G0537, G0538

Blood Draw: 36415, 36416 Screening:
Z00.00, Z00.01, Z13.220

Blood Draw: Z13.220 Age 40 through 75 years

Please refer to the plan's pharmacy benefit for details on cardiovascular disease options available under the plan's pharmacy preventive benefit.