Preventive Care Services - (A004) Form

.... 36 Bone Mineral Density Measurement Cervical Cancer Screening Visualization Technologies Colorectal Cancer Screening and Surveillance Contraceptives Genetic Testing for Hereditary Cancer Susceptibility

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Nucleic Acid Pathogen Testing Prescription Drug Lists and Coverage Member Resources PURPOSE Administrative Policies are intended to provide further information about the administration of standard Cigna benefit plans. In the event of a conflict, a customer’s benefit plan document always supersedes the information in an . Coverage determinations require consideration of 1) the terms of the applicable benefit plan document; 2) any applicable laws/regulations; 3) any relevant collateral source materials including Administrative Policies and; 4) the specific facts of the particular situation. Administrative Policies relate exclusively to the administration of health benefit plans. Administrative Policies are not recommendations for treatment and should never be used as treatment guidelines.

The Affordable Care Act (ACA) requires individual and group health plans to cover in-network preventive services and immunizations without cost sharing (e.g., deductibles, coinsurance, copayments) unless the plan qualifies under the grandfather provision or for an exemption. Coverage for preventive care services other than those mandated by ACA is dependent on benefit plan language. For example, many benefit plans specifically exclude immunizations that are for the purpose of travel or to protect against occupational hazards and risks. Please refer to the applicable benefit plan language to determine benefit availability and the terms, conditions and limitations of coverage. Services not covered under preventive care services may be covered under another portion of the health plan. Preventive care services are covered as required by the Affordable Care Act (ACA). The ACA designated resources that identify the preventive services required for coverage are: United States Preventive Services Task Force (USPSTF) grade A or B recommendations • Advisory Committee on Immunization Practices (ACIP) recommendations adopted by the Director of the Center for Disease Control and Prevention (CDC)

: A004 Health Resources and Services Administration (HRSA) supported comprehensive guidelines which appear in any of the following sources:

o Periodicity schedule of the Bright Futures Recommendations for Pediatric Preventive Health

Care o Uniform Panel of the Secretary’s Advisory Committee on Heritable Disorders in Newborns and

Children o Guidelines specifically issued for women and adopted by HRSA Note: ALL ICD-10, CPT® and HCPCS codes billed for a preventive service should follow standard coding guidelines, including those related to an unacceptable primary and principal diagnosis.

Wellness Examinations - General Description Preventive medicine comprehensive evaluation and management services (i.e., Wellness examinations) for well-baby, well-child and well-adult, including well-woman include: An age-and gender-appropriate history • Physical examination • Counseling/anticipatory guidance • Risk factor reduction interventions • The ordering of appropriate immunization(s) and laboratory/screening procedures Frequency of Wellness Examinations Ages 0 to age 5: According to the American Academy of Pediatrics (AAP) Bright Futures Periodicity Schedule 99381, 99382, 99391, 99392, 99461 Allowed with any diagnosis code Ages 5 and above: Annual wellness examination; annual well-woman exam; additional visits for women’s services related to contraception management 99383, 99384, 99385, 99386, 99387 99393, 99394, 99395, 99396, 99397 G0402, G0438, G0439, S0610, S0612, S0613 Allowed with any diagnosis code Preventive Care Services that may be provided during a Wellness Examination

Administration/Interpretation of Health Risk Assessment Instrument

Discussion of aspirin prophylaxis Autism screening

Discussion of chemoprevention with women at risk for breast cancer

Anxiety screening Discussion/referral for genetic counseling/evaluation for BRCA testing

Behavioral/Social/Emotional assessment

Hearing and vision screening

Blood pressure measurement for high blood pressure screening/Preeclampsia screening

Hepatitis B risk assessment

Breast-feeding promotion/counseling/support Intimate partner/interpersonal and domestic violence screening/referral to support services Counseling/education to minimize exposure to ultraviolet radiation Obesity screening/counseling regarding weight loss, healthy diet and exercise Counseling/education regarding FDA-approved contraception methods for women including counseling for continued adherence and follow- up, management of side effects, and instruction

Sudden cardiac arrest/sudden cardiac death risk assessment

: A004 in fertility awareness-based methods including the lactation amenorrhea method Counseling to prevent initiation of tobacco use

Tobacco use screening/counseling Counseling related to sexual behavior/sexually transmitted infection (STI) prevention including HIV Preexposure Prophylaxis (PrEP) related adherence counseling and pre- and post- prescription follow up counseling Oral health assessment/discussion of water fluoridation/referral to dental home Critical congenital heart disease screening Unhealthy Alcohol use and substance abuse screening/counseling

Depression screening/Maternal Depression screening/Suicide risk assessment

Urinary incontinence screening Preventive Care Screenings and Interventions (Note: some services may be provided as part of a wellness examination or at a separate encounter) The following codes represent services that are NOT for treatment of illness or injury and should be submitted with a designated wellness or maternity diagnosis code in the primary position on the claim form. Select a Designated Wellness Code from pertinent Code Group. Note: ALL ICD-10, CPT® and HCPCS codes billed for a preventive service should follow standard coding guidelines, including those related to an unacceptable primary and principal diagnosis. Some services MAY require precertification or other reasonable medical management technique or practice depending on benefit plan design. Abdominal Aortic Aneurysm Screening: Men, age 65-75 who have ever smoked

76706 Allowed with any diagnosis Administration/Interpretation of Health Risk Assessment Instrument (e.g., suicide risk assessment; sudden cardiac arrest/death risk assessment)

96160, 96161 Allowed with any diagnosis

Anemia, Iron Deficiency Anemia Screening: Children age 12 months 85013, 85014, 85018, 85025, 85027, 85041, G0306, G0307 Select Designated Wellness Code from Code Group 1 Anxiety Screening: adolescent and adult women including pregnant and postpartum women

96127, 96161 Allowed with any diagnosis Bacteriuria Screening: Pregnant women at 12- 16 weeks gestation or at the first prenatal visit, if later

87086, 87088 Allowed with a Maternity Diagnosis Code

Bilirubin Screening: newborns

82247, 88720 Select Designated Wellness Code from Code Group 1

: A004

Breast Cancer/Ovarian Cancer risk assessment: genetic counseling for women at risk BRCA1/BRCA2 Genetic Testing for susceptibility to breast or ovarian cancer, if indicated: women Breast Cancer Screening: women age 40 and older, with or without clinical breast exam, every 1-2 years Note: ACA utilizes the 2002 USPSTF recommendations on breast cancer screening.

Breast-feeding Support/Counseling during pregnancy and after birth

Breast-feeding Equipment/Supplies Cervical Cancer Screening >Pap smear: women age 21-65, every three years >HPV/DNA test alone or in combination with Pap smear: women age 30-65, every five years Chlamydia Screening: all sexually active women age 24 and younger, and older women at increased risk

Cholesterol Screening: children/adolescents

: A004

96040, S0265 Select Designated Wellness Code from Code Group 1

Subject to 3 visit limitation 81162, 81163, 81164, 81165, 81166, 81167, 81212, 81215, 81216, 81217 Allowed with any diagnosis (MAY require precertification or other reasonable medical management technique or practice depending on benefit plan design)

77065, 77066 Select Designated Wellness Code from Code Group 1

77063, 77067 Allowed with any diagnosis 99401, 99402, 99403, 99404, 99411, 99412, S9443 Allowed with any diagnosis Must be reported by non-network lactation consultants to be eligible for preventive coverage. A4281, A4282, A4283, A4284, A4285, A4286, A4287, E0602, E0603, E0604 Allowed with any diagnosis code E0604 requires a prescription Must be ordered through an in-network provider A starter kit is included at no cost, but there may be options to purchase upgrades (e,g,, wireless pumps) and accessories at a Cigna discounted rate. 87624, 87625, 88141, 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88164, 88165, 88166, 88167, 88174, 88175, 0500T Select Designated Wellness Code from Code Group 1 G0101, G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, G0476, P3000, P3001, Q0091 Allowed with any diagnosis 86631, 86632, 87110, 87270, 87320, 87490, 87491, 87492, 87800, 87801, 87810 Select Designated Wellness Code from Code Group 1; or Allowed with a Maternity Diagnosis Code 80061, 82465, 83718, 83721, 84478 >ages 9-11 years and 17-21 years >ages 2-8 years and 12-16 years with risk factors Cholesterol Screening: adults age 40-75 Colorectal Cancer Screening: consultation prior to colonoscopy Colorectal Cancer Screening: beginning at age 45 by any of the following methods: High-sensitivity guaiac fecal occult blood testing (HSgFOBT) or fecal immunochemical test (FIT) annually; or

Stool DNA-FIT every one to three years; or

Flexible sigmoidoscopy every five years; or

Flexible sigmoidoscopy every ten years + annual FIT; or

Colonoscopy screening every ten years; or

Computed tomographic colonography (virtual colonoscopy) every five years; or

Double contrast barium enema (DCBE) every five years Colonoscopy [screening] following positive results on stool-based screening tests and abnormal findings identified by flexible sigmoidoscopy or CT colonography

Congenital Hypothyroidism Screening: newborns

Critical Congenital Heart Disease Screening: newborns before discharge from hospital Depression Screening/Maternal Depression Screening: adolescents and adults including pregnant and postpartum women

: A004

Select Designated Wellness Code from Code Group 1 80061, 82465, 83718, 83721, 84478 Select Designated Wellness Code from Code Group 1

S0285 Allowed with any diagnosis 45330, 45331, 45333, 45338, 45346, 45378, 45380, 45381, 45384, 45385, 45388, 45390, 74270, 74280, 82270, 82274, 88305, 99152, 99153, 99156, 99157, G0500 Select Designated Wellness Code from Code Group 1 00812, 00813, 74263, 81528, G0104, G0105, G0106, G0120, G0121, G0122, G0328 Allowed with any diagnosis (74263 MAY require precertification or other reasonable medical management technique or practice depending on benefit plan design) 45378, 45380, 45381, 45384, 45385, 45388, 45390. 88305, 99152, 99153, 99156, 99157, G0500 Select Designated Wellness Code from Code Group 1

00812, 00813, G0105, G0121 Allowed with any diagnosis

84436, 84437, 84443 Select Designated Wellness Code from Code Group 1 Considered part of facility fee

96127, 96161, G0444 Allowed with any diagnosis

Depression and Suicide Risk Assessment (ages 12-21)

Developmental/Behavioral/Social/Emotional Screening Fall Prevention: community dwelling adults age 65 years and older with risk factors Fluoride application: infants and children birth to age 6 years (in primary care setting) Gestational Diabetes: pregnant women at first prenatal visit for those at risk; all pregnant women at 24 to 28 weeks gestation Gonorrhea Screening: all sexually active women age 24 and younger and older women at increased risk Gonorrhea prophylactic ocular medication to prevent blindness: newborns

Health Promotion/Prevention of Illness or Injury Counseling Hearing Screening: infants, children through age 10 years Hearing Screening: adolescents age 11 years through age 21 years (effective on or after 02/01/2018 as plans renew)

(not a complete hearing examination) Hepatitis B Screening: pregnant women, first prenatal visit; adolescents and adults at high risk for infection

: A004

96127, 96160, G0444 Allowed with any diagnosis

G0451 Select Designated Wellness Code from Code Group 1

96110, 96127, S0302 Allowed with any diagnosis 97110, 97112, 97113, 97116, 97150, 97161, 97162, 97163, 97164, 97530, G0159, S8990, S9131 Select Designated Wellness Code from Code Group 2

Age Limitation applied

99188, 0792T Allowed with any diagnosis

82950, 82951, 82952 Allowed with a Maternity Diagnosis Code 87590, 87591, 87800, 87801, 87850 Select Designated Wellness Code from Code Group 1; or Allowed with a Maternity Diagnosis Code No specific code; typically included on hospital billing 99401, 99402, 99403, 99404, 99411, 99412 Allowed with any diagnosis code 92550, 92552, 92553, 92558, 92567, 92568, 92579, 92582, 92583, 92587, 92588, 92650, 92651, 92652, 92653 Select Designated Wellness Code from Code Group 1

92551, V5008 Allowed with any diagnosis

Age Limitations applied 86704, 86705, 86706, 87340, 87341 Select Designated Wellness Code from Code Group 1; or Allowed with a Maternity Diagnosis Code

G0499 Allowed with any diagnosis

Hepatitis C Screening: adults aged 18-79 High Blood Pressure Screening (Outside the Clinical Setting): adults age 18 and older Human Immunodeficiency Virus (HIV) Infection Screening: pregnant women, adolescents and adults 15 to 65 years; younger adolescents or adults with risk factors; annually for sexually active women (adolescent and adult)

Lead Screening: children at risk for lead exposure Lung Cancer Counseling to discuss need for Screening Lung Cancer Screening: annually for adults age 50 to 80 with 20 pack-year smoking history, and currently smoke, or have quit within the past 15 years Metabolic Screening: newborns (specific combination of tests will vary according to state law) Nutrition/Physical Activity Counseling, Behavioral Interventions: adults who have risk factors for cardiovascular disease; obese adults and children age six years and older

: A004 86803, 87522 Select Designated Wellness Code from Code Group 1; or Allowed with a Maternity Diagnosis Code

G0472 Allowed with any diagnosis 93784, 93786, 93788, 93790, 99473, 99474, A4660, A4663, A4670 Select Designated Wellness Code from Code Group 6 Requires a prescription Must be ordered through an in-network provider 80081, 86701, 86702, 86703,87389, 87390, 87391, 87534, 87535, 87536, 87537, 87538, 87806, S3645 Select Designated Wellness Code from Code Group 1; or Allowed with a Maternity Diagnosis Code

G0432, G0433, G0435, G0475 Allowed with any diagnosis

83655 Select Designated Wellness Code from Code Group 1

G0296 Allowed with any diagnosis

71271 Allowed with any diagnosis (MAY require precertification or other reasonable medical management technique or practice depending on benefit plan design)

S3620 Allowed with any diagnosis 97802, 97803, 97804, S9470 Select Designated Wellness Code from Code Group 1 Subject to 3 visit limitation

G0446, G0447, G0473 Allowed with any diagnosis

Nutrition/Physical Activity Counseling, Behavioral Interventions: Pregnant adolescents and adults Obesity Prevention in midlife women (age 40-60 with normal or overweight body mass index (BMI); nutrition/physical activity counseling Osteoporosis Screening: women age 65 or older (or younger women with fracture risk as determined by a formal Clinical Risk Assessment Tool)

Perinatal Depression Prevention, Interventions: Pregnant and postpartum women

Phenylketonuria (PKU) Screening: newborns Prediabetes and Type 2 Diabetes Screening and Counseling: Adults, age 35-70 who are overweight or obese; women with a history of gestational diabetes

Prevention of Human Immunodeficiency Virus (HIV) Infection: Preexposure Prophylaxis (PrEP)

Oral and Injectable Medication

Related services: Includes: HIV screening; Kidney function testing (effective 9/17/2021); Hepatitis B and C Screening; Pregnancy testing as appropriate (effective 9/17/2021); Sexually Transmitted Infection Screening and Behavioral Counseling; STI Adherence Counseling

: A004 97802, 97803, 97804, S9470 Allowed with a Maternity Diagnosis Code Subject to 3 visit limitation 97802, 97803, 97804, S9470 Select Designated Wellness Code from Code Group 1 Subject to 3 visit limitation 76977, 77078, 77080, 77081, G0130 Select Designated Wellness Code from Code Group 1 (77078 MAY require precertification or other reasonable medical management technique or practice depending on benefit plan design) 96156, 96158, 96159, 96164, 96165, 96167, 96168 Allowed with a Maternity Diagnosis Code

84030 Select Designated Wellness Code from Code Group 1 82947, 82948, 82950, 82951, 82952, 83036, G9886, G9887, G9888 Select Designated Wellness Code from Code Group 1 0403T, 0488T, G9873, G9874, G9875, G9876, G9877, G9878, G9879, G9880, G9881, G9882, G9883, G9884, G9885, G9890 Allowed with any diagnosis

HIV Screening: For coding guidance, see Human Immunodeficiency Virus (HIV) Infection Screening G0012, J0739, J0750, J0751, J0799, Q0516, Q0517, Q0518 Select Designated Wellness Code from Code Group 1

Kidney function testing:

82565, 82575, 82610 Select Designated Wellness Code from Code Group 1

Hepatitis B Screening: For coding guidance, see Hepatitis B Screening

Hepatitis C Screening: For coding guidance, see Hepatitis C Screening

Individual counseling for preexposure prophylaxis Note: Refer to the plan’s pharmacy benefit for details on prescription medications available under the plan’s preventive benefit. Prostate Cancer Screening: men age 45 and older or age 40 with risk factors Rh incompatibility Screening: pregnant women at first visit and repeat for unsensitized Rh negative women at 24-28 weeks

Routine Immunizations • COVID-19 • Diphtheria, Tetanus Toxoids and

Acellular Pertussis (DTaP, Tdap, Td) Dengue (recommended for certain populations only)

Haemophilus influenza type b conjugate (Hib)

Hepatitis A (Hep A) • Hepatitis B (Hep B) • Human Papillomavirus (HPV) • • Measles, mumps and rubella (MMR) Influenza

: A004

Pregnancy Testing:

81025, 84703 Select Designated Wellness Code from Code Group 1 Sexually Transmitted Infection (STI) Screening and Behavioral Counseling: For coding guidance see the following sections:

Chlamydia Screening

Gonorrhea Screening

Syphilis Screening

STI Prevention Counseling

Adherence Counseling/Pre and Post-Prescription follow-up counseling: 99401, 99402, 99403, 99404, 99411, 99412 Allowed with any diagnosis

Individual Counseling for preexposure prophylaxis:

G0011, G0013 Select Designated Wellness Code from Code Group 1

84152, 84153, 84154 Select Designated Wellness Code from Code Group 1

G0103 Allowed with any diagnosis

86900, 86901 Allowed with a Maternity Diagnosis Code 90380, 90381, 90460, 90461, 90471, 90472, 90473, 90474, 90480, 90587, 90619, 90620, 90621, 90623, 90630, 90632, 90633, 90634, 90636, 90644, 90647, 90648, 90649, 90650, 90651, 90662, 90670, 90671, 90672, 90674, 90677, 90678, 90679, 90680, 90681, 90682, 90883, 90686, 90687, 90688, 90694, 90696, 90697, 90698, 90700, 90702, 90707, 90710, 90713, 90714, 90715, 90716, 90723, 90732, 90733, 90734, 90736, 90739, 90740, 90743, 90744, 90746, 90747, 90748, 90750, 90756, 91304, 91318, 91319, 91320, 91321, 91322, 96380, 96381, G0008, G0009,G0010, J3530, M0201, Q2034, Q2035, Q2036, Q2038, Q2039 Meningococcal (MCV) • Pneumococcal • Poliovirus (IPV) • Respiratory Syncytial Virus (RSV) • Rotavirus (RV) • Varicella • Zoster Sexually Transmitted Infection (STI) Prevention Counseling: sexually active adolescents and adults at increased risk

Sickle Cell Disease Screening: newborns Smoking and Tobacco Use Cessation Counseling/Interventions: adults and pregnant women who smoke Syphilis Screening: pregnant women and persons at increased risk of infection Tuberculosis Screening: children, adolescents and adults at increased risk

Unhealthy Alcohol Use/Substance Abuse Screening and Counseling: All adults, adolescents age 11-21

Unhealthy Drug Use Screening: All adults, age 18 and older

Venipuncture for Preventive Laboratory Screenings

Vision Screening: age 3 through age 15 (not a complete vision examination) Instrument based screening recommended for risk assessment at ages 12 and 24 months in addition to the well visits at 3-5 years of age.

Women’s Contraceptive Services

: A004 Allowed with any diagnosis code (90649, 90650, 90651 are subject to age limits depending on FDA licensed indications and ACIP recommendations for Dates of Service prior to 02-16- 2019 99401, 99402, 99403, 99404, 99411, 99412, G0445 Allowed with any diagnosis

85660 Select Designated Wellness Code from Code Group 1

99406, 99407 Allowed with any diagnosis code 86592, 86593, 86780, 0064U Select Designated Wellness Code from Code Group 1; or Allowed with a Maternity Diagnosis Code

86480, 86481, 86580 Select Designated Wellness Code from Code Group 1 99408, 99409, G0396, G0397, G0442, G0443, G2011 Allowed with any diagnosis

99408, 99409, G0396, G0397, G2011 Allowed with any diagnosis 36415, 36416 Select Designated Wellness Code from Code Group 1; or Allowed with a Maternity Diagnosis Code

99173, 99174, 99177 Allowed with any diagnosis

Age Limitation applied Services for insertion/removal of intrauterine devices, implants; fitting diaphragm or cervical cap 11976, 11981, 11982, 11983, 57170 58300, 58301, S4981 Allowed with any diagnosis code

Contraceptive Supplies A4261, A4266, A4267, A4268, A4269, J7294, J7295, J7304 Allowed with any diagnosis code

Intrauterine devices (ParaGard®, Skyla®, Kyleena™, Liletta™ Mirena®,)

J7300, J7301, J7296, J7297, J7298 Allowed with any diagnosis code

Injection (Depot medroxyprogesterone acetate)

J1050, 96372 Select Designated Wellness Code from Code Group 4

Implants

J7307 Allowed with any diagnosis code

58661 Select Designated Wellness Code from Code Group 3

Surgical sterilization procedures for women 00851, 58600, 58605, 58611, 58615, 58670, 58671 Allowed with any diagnosis code Pathology service related to surgical sterilization procedures for women

88302 Select Designated Wellness Code from Code Group 5

General Background Preventive care services are those screenings, tests, and services that are performed for symptom-free or disease-free individuals. They may also include routine immunization and wellness screening services for symptom-free or disease-free individuals at increased risk for a particular disease. Typically, preventive care services must be provided by in-network health care professionals. Ancillary services directly related to a screening colonoscopy or female sterilization procedures are considered part of the preventive service. This includes a pre-procedure evaluation office visit, the facility fee, anesthesia services, and pathology services. ACA has designated specific resources for coverage by the Act: which include the evidenced-based items or services that have in effect a rating of “A” or “B” in the current recommendations of the USPSTF; immunizations for routine use in children, adolescents, and adults that have in effect a recommendation from the ACIP of the CDC; for infants, children, and adolescents, the evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the HRSA; and with respect to women, evidence-informed preventive care and screening provided for in comprehensive guidelines supported by HRSA. If a recommendation or guideline does not specify the frequency, method, treatment, or setting for the provision of that service, reasonable medical management techniques may be used to determine any coverage limitations. Professional society statements and guidelines may vary and are not considered part of ACA sources.

: A004 According to the ACA, coverage of preventive services become effective upon a plan’s start or anniversary date that is one year after the date the recommendation or guideline is issued. The USPSTF assigns each recommendation a letter grade based on the strength of the evidence and the balance of benefits and harms of a preventive service. If a Grade A or B recommendation changes to a Grade C or I, coverage must be provided through the last day of the plan year. If a Grade A or B recommendation changes to a Grade D, or any previously recommended service is subject to a safety recall or is otherwise determined to pose a significant safety concern, there is no requirement to provide coverage through the last day of the plan year.

Grade A U.S. Preventive Services Task Force Letter Grade Descriptions The USPSTF recommends the service. There is high certainty that the net benefit is substantial.

Grade B

Grade C

Grade D

Grade I The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small. The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined. 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 utilized to determine frequency, method, treatment or setting for the provision of a recommended preventive service. Screening Versus Diagnostic, Monitoring or Surveillance Testing Screening exams are performed in individuals who are symptom and disease free. Diagnostic tests are performed to evaluate abnormalities (e.g., lab results, physical findings or symptoms). Monitoring or surveillance testing is performed in individuals who have a known condition or history that increases the risk of disease and is no longer considered a screening exam. A positive result on a preventive screening exam does not alter its classification as a preventive service but does influence how that service is classified when rendered in the future. For example, if a screening colonoscopy performed on an asymptomatic individual without additional risk factors for colorectal cancer (e.g. adenomatous polyps, inflammatory bowel disease) detects colorectal cancer or polyps, the purpose of the procedure remains screening, even if polyps are removed during the preventive screening. However, once a diagnosis of colorectal cancer or additional risk factors for colorectal cancer are identified, future colonoscopies will no longer be considered preventive screening. Positive results on stool-based screening tests and abnormal findings identified by flexible sigmoidoscopy or CT colonography require follow-up with colonoscopy for screening benefits to be achieved (USPSTF, 2021). Reporting Preventive Care Services ALL ICD-10, CPT® and HCPCS codes billed for a preventive service should follow standard coding guidelines, including those related to an unacceptable primary and principal diagnosis. Preventive care services are reported with diagnosis and procedure codes which identify the services as preventive and not for treatment of injury or illness. (Reference chart below). Age or frequency limits are utilized for certain designated services (i.e., wellness exams, vision and hearing screening, services related to prevention of falls, nutritional and genetic counseling). Preventive care services submitted with diagnosis codes that represent treatment of illness or injury will be paid as applicable under normal medical benefits rather than preventive care coverage.

Modifier 33

: A004 Cigna does not process preventive care claims solely based on the presence of modifier 33, which was developed by the industry in response to the ACA’s preventive service requirements. Preventive care services are dependent upon claim submission using preventive diagnosis and procedure codes in order to be identified and covered as preventive care services. Additional Preventive Care Services In addition to the designated services identified by ACA sources, adult wellness examinations, prostate cancer screening, double contrast barium enema for colorectal cancer screening, digital breast tomosynthesis for breast cancer screening, and venipuncture associated with preventive laboratory screenings are covered under the benefit as preventive care services. Professional society statements and guidelines may vary and are not considered part of ACA sources