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

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

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

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

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

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

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

Subject to change as regulations and further clarifications are received.

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

Please note that the coding represented in the policy does not take into consideration bundling and editing rules that may apply to them.

Policy: 
ABDOMINAL AORTIC ANEURYSM, SCREENING
USPSTF Recommendation
The USPSTF recommends one-time screening for abdominal aortic aneurysm (AAA) screening for men ages 65 – 75 who have ever smoked. (Grade B)

CPT/HCPCS Codes
G0389 — Ultrasound b-scan and/or real time with image documentation; for abdominal aortic aneurysm (aaa) screening 
76706 (effective 1/1/2017) — Ultrasound, abdominal sorta, real time with image documentation, screening study for abdominal aortic aneurysm (AAA)

ICD-9 Codes
V15.82 — Personal history of tobacco use, presenting hazards to health
V81.2 — Other and unspecified cardiovascular conditions

ICD-10 Codes
Z87891
Z136

ALCOHOL AND DRUG USE SCREENING FOR ADOLESCENTS BEGINNING AT AGE 11 – 18  

HRSA (Bright Futures) Recommendation 

Bright Futures recommends initiating questioning regarding alcohol or drug use and, if positive, to follow with an alcohol or drug screening tool.

 

CPT/HCPCS Code

CPT 99408

 

ANEMIA, SCREENING IN INFANTS, CHILDREN & ADOLESCENTS

HRSA (Bright Futures) Recommendations

Hemoglobin and hematocrit should be screened for at the 4-month well-child visit in children who are preterm or who are low birth weight infants, and those not on iron-fortified formula.

Hemoglobin and hematocrit should be screened for routinely at the 12-month well-child visit.

Hemoglobin and hematocrit should be screened selectively for children who are positive for risk screening questions at the 15 month – 21 year visits.

 

CPT/HCPCS Codes

CPT 85014

CPT 85018 

ANXIETY DISORDERS IN ADULTS: SCREENING ADULTS 64 YEARS OR YOUNGER, INCLUDING PREGNANT AND POSTPARTUM PERSONS:

The USPSTF recommends screening for anxiety disorders in adults , including pregnant and postpartum persons.

CPT/HCPCS codes

CPT 99420 administration and interpretation of health risk assessment instrument

CPT 96160 administration of patient focused health risk assessment instrument

CPT 96161 administration of caregiver focused health risk assessment instrument

HCPCS G0444

ICD 9 V79.0

ICD10 Z1331

ASPIRIN TO PREVENT CARDIOVASCULAR DISEASE IN ADULTS

EFFECTIVE 07012024 THIS BENEFIT WILL TERMINATE AS THE USPSTF HAS DECREASED THIS RECOMMENDATION TO A C/D RECOMMENDATION.

USPSTF Recommendations
The USPSTF recommends the use of aspirin for men age 45 to 79 years when the potential benefit due to a reduction in myocardial infarctions outweighs the potential harm due to an increase in gastrointestinal hemorrhage. (Grade A)

The USPSTF recommends the use of aspirin for women age 55 to 79 years when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage. (Grade A) 

USPSTF recommendation updated April 2016: 

The USPSTF recommends initiating low-dose aspirin use for the primary prevention of cardiovascular disease and colorectal cancer in adults aged 50 to 59 years who have a 10% or greater 10-year cardiovascular risk, are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years. 

Aspirin Use To Prevent Preeclampsia and Related Morbidity and Mortality: Preventive Medication: Pregnant Persons at High Risk for Preeclampsia:

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

Asymptomatic pregnant persons:

The USPSTF recommends screening for hypertensive disorders of pregnancy with blood pressure measurements throughout pregnancy.

ICD 9 V81.1

ICD 10 Z136

AUTISM, SCREENING 

HRSA (Bright Futures) Recommendation 

Provide the autism specific screening test at the 18-month and 24-month well-child visits.

 

CPT/HCPCS Codes
CPT 96110

 

HCPCS G0451

Anxiety in Children and Adolescents: Screening: Children and adolescents aged 8 – 18 years

The USPSTF recommends screening for anxiety in children and adolescents 8 – 18 years

CPT/HCPCS codes

CPT 99420-administration and interpretation of health risk assessment instrument

CPT 96160 administration of patient-focused health risk assessment instrument

CPT 96161 administration of caregiver-focused health risk assessment instrument

CPT 96127 brief emotional/behavioral assessment with scoring and documentation per standardized instrument

HCPCS G0444

ICD9 V79.0

ICD10 Z1331

BACTERIURIA, SCREENING IN PREGNANT WOMEN

USPSTF Recommendation

The USPSTF recommends screening for asymptomatic bacteriuria using urine culture in pregnant persons. (Grade B)

 

CPT/HCPCS Code
CPT 87086

 

ICD-9 Codes

V22.0 – V22.2 — Prenatal visits

V23.0 – V23.9 — Prenatal visits for patients with high-risk pregnancies

ICD-10 Codes

Z34 – Z3493

Z331

O0900 – O0993

 

BRCA TESTING, RISK ASSESSMENT GENETIC COUNSELING/TESTING

USPSTF RECOMMENDATION
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 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. (grade B)

CPT/HCPCS Codes:
CPT 99385 – 99387

CPT 99395 – 99397

CPT 8211 (Code deleted effective 01/01/2019)

CPT 81212 – 81217 (code effective 01/01/2019)

CPT 81162

CPT 81163 – 81167

CPT 96040

HCPCS S0265

ICD-9 Codes
V16.3 — Family history of breast cancer

V16.40 — Family history of malignant neoplasm, unspecified genital organ

V16.41 — Family history of ovarian cancer

V26.33 — Genetic counseling

ICD-10 Codes
Z803

Z8049

Z8041

Z315

BREAST CANCER, PREVENTIVE MEDICATION
USPSTF Recommendation

The USPSTF recommends that clinicians 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. (Grade B) 

CPT Codes
CPT 99401 – 99404

ICD-9 Codes
V16.3

V84.01

ICD-10 Codes
Z803

Z1501

BREAST CANCER, SCREENING (MAMMOGRAPHY)

USPSTF Recommendation

The USPSTF currently recommends biennial screening mammography for women with or without clinical breast examination, every 1 – 2 years for women aged 40 of age and older. (Grade B)

CPT/HCPCS Codes
CPT 77052 (code deleted as of 1/1/2017)

CPT 77057 (code deleted as of 1/1/2017)

CPT 77067 (effective 1/1/2017) — Screening mammography, bilateral (2-view study of each breast), including computer-aided detection )CAD) when performed

CPT 77062 - Digital breast tomosynthesis; bilateral 

CPT 77063 - Screening digital breast tomosynthesis, bilateral 

HCPCS G0202

ICD-9 Codes
V76.10 — Breast screening, unspecified

V76.11 — Screening mammogram for high-risk patient

V76.12 — Other screening mammogram

V76.19 — other screening breast examination

ICD-10 Codes
Z1239

Z1231

 

BREASTFEEDING, COUNSELING

USPSTF Recommendation

The USPSTF recommends interventions during pregnancy and after birth to promote and support breastfeeding. (Grade B)

CPT/HCPCS Codes
HCPCS S9443 - Lactation classes, non-physician provider, per session 

ICD-9 Codes
V22.0 – V24.2

V24.1 — Postpartum care and examination of lactating mothers.

ICD-10 Codes
Z34 – Z3493

Z331

Z390 – Z392

O0900 – O0993

NOTE: CAM 046 also addresses breast pumps and indicates the following two breast pumps are allowable for members who qualify for no cost sharing: the Ameda Purely Yours electric pump and the Ameda One Hand Manual pump. 

CERVICAL CANCER, SCREENING

USPSTF Recommendation

The USPSTF recommends screening for cervical cancer 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). 

HRSA (Bright Futures) Recommendation

Bright Futures recommends screening for cervical dysplasia with Pap smear within 3 years of onset of sexual activity

 

CPT/HCPCS Codes

CPT 87623 – 87625

CPT 88141 – 88153

CPT 88164 – 88167

CPT 88174 – 88175

CPT 87626

CPT 0500T (removed effective 1/1/25)

HCPCS G0101 

HCPCS G0123 – G0124

HCPCS G0144 – G0145

ICD-9 Codes
V723 — Gynecological exam

V72.31 — Routine gynecological examination

V72.32 — Encounter for Papanicolaou cervical smear to confirm findings of recent normal smear following initial abnormal smear

V73.81 — Special screening examination for human papillomavirus (HPV)

V76.2 — Special screening for malignant neoplasm of the cervix

ICD-10 Codes
Z01411

Z01419

Z0142

Z124

Z1151

CHLAMYDIA INFECTION, SCREENING IN WOMEN AND ADOLESCENTS
USPSTF Recommendation

The USPSTF recommends screening for chlamydial infection for all sexually active non-pregnant young women aged 24 and younger and for older non-pregnant women who are at increased risk. (Grade A)

                                                                  AND

The USPSTF recommends screening for chlamydial infection for all pregnant women age 24 and younger and for older pregnant women who are at increased risk. (Grade B)

Effective 09/2021 The USPSTF recommends screening for chlamydia in all sexually active women, including pregnant persons, 24 years or younger and in women 25 years or older who are at increased risk for infection.

HRSA (Bright Futures) Recommendation

Screen sexually active adolescents for chlamydia using tests appropriate to the patient population and clinical setting.

CPT/HCPCS Codes

CPT 87490

CPT 87491

 

ICD-9 Codes

V73.88 — Special screening examination for other specified chlamydial diseases

V73.98 — Special screening examination for unspecified chlamydial disease

V016 — Contact with or exposure to venereal diseases

ICD-10 Code

Z118

Z202

Z7251

Z7252

Z7253

COLORECTAL CANCER, SCREENING

USPSTF Recommendation

Effective May 31, 2022, the USPSTF recommendation has been expanded to include coverage of a follow up colonoscopy without cost share after a positive non-invasive stool- based test or direct visualization.

The USPSTF recommends screening for colorectal cancer starting at age 50 years and continuing until age 75 years. (Recommendation changed effective May 18, 2021.)

Effective May 18, 2021, the USPSTF recommends screening for colorectal cancer for all adults age 45 and continuing until age 75 years.

CPT/HCPCS Codes:

Use of the 33 modifier with specific surgical codes will help identify the procedure as preventive; policy for.

CPT 00810

CPT 00812 (Report 00812 to describe anesthesia for any screening colonoscopy regardless of ultimate findings)

CPT 45330 – 45349

CPT 45378 – 45392

CPT 81528

CPT 82270

CPT 82274

HCPCS G0104

HCPCS G0105

HCPCS G0106

HCPCS G0120

HCPCS G0121

HCPCS G0122

HCPCS G0328

HCPCS effective May 1, 2016, S0285 — Colonoscopy consultation performed prior to a screening colonoscopy procedure

ICD-9 Codes

V76.41 — Screening for malignant neoplasm of the rectum 

V76.51 — Special screening for malignant neoplasms, Colon

ICD-10 Codes

Z1212

Z1211

CONGENITAL/INHERITED METABOLIC DISORDERS AND HEMOGLOBINOPATHIES

HRSA (Bright Futures) Recommendation

These tests are usually done prior to discharge from the hospital following birth of the infant), but may be allowed up to 30 days of age.

CPT/HCPCS Code

S3620

 

DENTAL CARIES IN PRESCHOOL CHILDREN

USPSTF Recommendation

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 in primary care practices. The USPSTF recommends primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is fluoride deficient. (Grade B)

HRSA (Bright Futures) Recommendation

Oral fluoride supplementation from ages 1 – 6 if the primary water source is deficient in fluoride.

 

CPT HCPCS Codes

99188

D1208 

 

DEPRESSION, SCREENING IN ADULTS

USPSTF Recommendation

The USPSTF recommends screening adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up. (Grade B)

Updated verbiage June 2023:

DEPRESSION AND SUICIDE RISK IN ADULTS: SCREENING ADULTS, INCLUDING PREGNANT AND POSTPARTUM PERSON, AND OLDER ADULTS (65 YEARS OR OLDER)

The USPSTF recommends screening for depression in the adult population, including pregnant and post partum persons, as well as older adults.

CPT/HCPCS Codes

CPT 99420 — Administration and Interpretation of health risk assessment instrument (e.g., health hazard appraisal)

CPT 96160 (effective Jan. 1, 2017) — Administration of patient-focused health risk assessment instrument (e.g., health hazard appraisal) with scoring and documentation, per standardized instrument

CPT 96161 (effective Jan. 1, 2017) — Administration of caregiver-focused health risk assessment instrument (e.g., depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument

CPT 96127 — Brief emotional/behavioral assessment (e.g., depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument.

HCPCS: G0444

 

ICD-9 Code

V79.0 Screening for depression

ICD-10 Code

Z1331

DEPRESSION, SCREENING IN ADOLESCENTS

USPSTF Recommendation

The USPSTF recommends screening of adolescents (12 – 18 years of age) for major depressive disorder (MDD) when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal), and follow-up. (Grade B)

Updated recommendation 10/2022: Depression and Suicide Risk in children and Adolescents: Screening adolescents aged 12 – 18 years:

The USPSTF recommends screening for major depressive disorder (MDD) in adolescents aged 12 – 18.

CPT /HCPCS Codes

CPT 99420 — Administration and Interpretation of health risk assessment instrument (e.g., health hazard appraisal)

CPT 96160 (effective Jan. 1, 2017) — Administration of patient-focused health risk assessment instrument (e.g., health hazard appraisal) with scoring and documentation, per standardized instrument

CPT 96161 (effective Jan. 1, 2017) — Administration of caregiver-focused health risk assessment instrument (e.g., depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument

CPT 96127 — Brief emotional/behavioral assessment (e.g., depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument.

HCPCS: G0444

ICD-9 Code

V79.0 Screening for depression

ICD-10 Code

Z1331

 

DEVELOPMENTAL SCREENING

HRSA (Bright Futures) Recommendation

Begin structured developmental screening at the 9-month well-child visit with repeat evaluation at the 18-month and the 2½-year well-child visits.

 

CPT/HCPCS Codes

CPT: 96110

(This code is recommended by the AAP [Coding for Pediatric Preventive Care, 2011].)

HCPCS: G0451

 

DIABETES MELLITUS, TYPE 2, SCREENING IN ADULTS

USPSTF Recommendation

The USPSTF recommends screening for Type 2 Diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg. (Grade B)

 

Diabetes Screening verbiage was updated in October 2015 to state the following:
The USPSTF recommends screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged 40 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. (grade B)

 

Diabetes Screening verbiage was updated in August 2021 to state the following:

 

Screening for Prediabetes and Type 2 Diabetes: asymptomatic adults aged 35 – 70 years who have overweight or obesity:

 

The USPSTF recommends screening for prediabetes and Type 2 diabetes in adults aged 35 – 70 years who have overweight or obesity. Clinicians should offer to refer patients with prediabetes to effective preventive interventions.

 

CPT/HCPCS Codes

CPT 82947

CPT 82948

 

ICD-9 Code

V77.1 — Screening for diabetes mellitus

 

ICD-10 Code

Z131

R7303

 

DIABETES MELLITUS, SCREENING IN PREGNANT WOMEN 24 – 28 WEEKS GESTATION AND AT FIRST PRENATAL VISIT FOR PREGNANT WOMEN IDENTIFIED AS HIGH RISK FOR DIABETES

 

Gestational Diabetes screening was changed in August of 2021 to state:

 

Gestational Diabetes: Screening: asymptomatic pregnant persons at 24 weeks of gestation or after:

 

The USPSTF recommends screening for gestational diabetes in asymptomatic pregnant persons at 24 weeks of gestation or after.

 

USPSTF Recommendation

The USPSTF recommends screening for gestational diabetes mellitus in asymptomatic pregnant women after 24 weeks of gestation. (Grade B)

 

CPT/HCPCS Codes

CPT 82947

CPT 82948

 

ICD-9 Code:

V77.1 — Screening for diabetes mellitus

 

ICD-10 Code

Z131

 

DIABETES MELLITUS, SCREENING IN PREGNANT WOMEN 24 – 28 WEEKS GESTATION AND AT FIRST PRENATAL VISIT FOR PREGNANT WOMEN IDENTIFIED AS HIGH RISK FOR DIABETES

USPSTF Recommendation

The USPSTF recommends screening for gestational diabetes mellitus in asymptomatic pregnant women after 24 weeks of gestation. (Grade B)

 

CPT/HCPCS Codes

CPT 82947

CPT 82948

CPT 82950

 

ICD-9 Codes

V22.0 – V22.2

V23.0 – V23.9

V77.1 — Screening for diabetes mellitus

 

ICD-10 Codes

Z34 – Z3493

Z331

O0900 – O0993

Z131

 

FALLS, PREVENTION IN COMMUNITY-DWELLING OLDER ADULTS

USPSTF Recommendation

 

The USPSTF recommends exercise interventions to prevent falls in community-dwelling adults 65 years or older who are at increased risk for falls.

FOLIC ACID, PREVENTION OF NEURAL TUBE DEFECTS

USPSTF Recommendation

The USPSTF recommends that all women planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 to 800 µg) (Grade A) of folic acid. Not routinely covered for “all women capable of pregnancy.” (Grade A)

Updated verbiage August 2023:

The USPSTF recommends that all persons planning to or who could become pregnant take a daily supplement containing 0.4 to 0.8 (400-800 mcg) of folic acid.

 

CPT/HCPCS Code

A9152   

 

GONORRHEA, PROPHYLACTIC MEDICATION: NEWBORNS 

USPSTF Recommendation

 

The USPSTF recommends prophylactic ocular topical medication for all newborns to prevent gonococcal ophthalmia neonatorum (Grade A).

ICD-9 Code:

V20.2  

 

ICD-10 Codes

Z00129 

Z298 code terms 10/01/2023 and is replaced by Z2989

 

CPT code: J3490

Of note, this will typically be included in the newborn hospital claim.

 

GONORRHEA, SCREENING 

USPSTF Recommendation

The USPSTF recommends that clinicians screen all sexually active women, including those who are pregnant, for gonorrhea infection if they are at increased risk for infection. (Grade B)

 

Effective 09/2021:

 

The USPSTF recommends screening for gonorrhea in all sexually active women, including pregnant persons, 24 years or younger and in women 25 years or older who are at increased risk for infection. 

 

HRSA (Bright Futures) Recommendation

Screen sexually active adolescents for gonorrhea using tests appropriate to the patient population and clinical setting.

 

CPT/HCPCS Codes

CPT 87590

CPT 87591

CPT 87850

 

ICD-9 Codes

V016

V70.0

V72.3

V72.31

V74.5

V22.0 – V24.2

 

ICD-10 Codes

Z0000

Z01411

Z01419

Z113

Z202

Z34 – Z3493

Z331

Z390 – Z392

Z7251 – Z7253

O0900 – O0993

 

Healthy Weight and Weight Gain in Pregnancy: Behavioral Counseling Interventions: Pregnant Persons:

The USPSTF recommends that clinical offer pregnant persons effective behavioral counseling interventions aimed at promoting healthy weight gain and preventing excess gestational weight gain in pregnancy:

 

CPT

99401 – 99404

99411 – 99412

G0473

G0477

 

ICD 9:

V220 – V239

64200 – 65161

 

ICD 10:

All coding starting with O

 

HEARING LOSS, SCREENING IN NEWBORNS USPSTF Recommendation

The USPSTF recommends screening for hearing loss in all newborn infants (less than one month of age). (Grade B)

 

After the 4th month, if there are positive responses to risk screening questions, the infant should be referred for diagnostic audiologic assessment.

HRSA (Bright Futures) Recommendation

If not done at birth (e.g., newborn delivered at home or discharged from Neonatal Intensive Care Unit) screening should be completed within the first month of life.

After the 4th month, if there are positive responses to risk screening questions, the infant should be referred for diagnostic audiologic assessment.

At years 4, 5, 6, 8 and 10, audiometry is recommended.

Audiometry screening with 6,000 and 8,000 Hz high frequency is recommended once between 11 through 14 years of age, once between 15 through 17 years of age and once between 18 through 21 years of age.

 

CPT/HCPCS Codes

CPT 92551

CPT 92552

CPT 92558

CPT 92586

CPT 92650

CPT 92651

CPT 92652

CPT 92653

 

ICD-9 Codes

V30 – V39 

 

ICD-10 Codes

Z380 – Z388

 

HEPATITIS B SCREENING: nonpregnant adolescents and adults:

The USPSTF recommends screening for hepatitis B virus infection in persons at high risk for infection.

 

CPT /HCPCS Codes

CPT 80055

CPT 80081

CPT 87340

 

CDC guidance for high risk for infection includes:

• Persons born in geographic regions with HBsAg prevalence of > 2%.
• U.S.-born persons not vaccinated as infants whose parents were born in geographic regions with HBsAg prevalence of > 8%.
• Injection-drug users.
• Men who have sex with men.
• Persons with elevated ALT/AST of unknown etiology.
• Persons with selected medical conditions who require immunosuppressive therapy.
• Pregnant women.
• Infants born to HBsAg-positive mothers.
• Household contacts and sex partners of HBV-infected persons.
• Persons who are the source of blood or body fluid exposures that might warrant post-exposure prophylaxis (e.g., needlestick injury to a health care worker).
• Persons infected with HIV.

ICD 10:

Z7251 – Z7253

F11 – F169

F18 – F199

HEPATITIS B VIRUS INFECTION IN PREGNANCY, SCREENING

USPSTF Recommendation

The USPSTF strongly recommends screening for hepatitis B virus infection in pregnant women at their first prenatal visit (Grade A).

 

CPT/HCPCS Codes

CPT 80055

CPT 80081

CPT 87340

 

ICD-9 Codes

V22.0 – V22.2 — Prenatal Visits

V23.0 – V23.9 — Prenatal visits for patients with high risk pregnancies

V28.9 – Antenatal screening NOS

 

ICD-10 Codes

Z34 – Z3493

O0900 – O0993

Z36

 

HEPATITIS C VIRUS INFECTIONS SCREENING IN ADULTS

USPSTF Recommendation

The USPSTF recommends screening for hepatitis C virus (HCV) infection in persons at high risk for infection. The USPSTF also recommends offering one-time screening for HCV infection to adults born between 1945 and 1965. (Grade B)

 

Verbiage for hepatitis C screening updated by the USPSTF March 2020:

 

The USPSTF recommends screening for hepatitis C virus (HCV) infection in adults ages 18 to 79 years.

 

CPT/HCPCS Codes

CPT 86803 – 86804

HCPCS G0472

 

ICD 10

Z7251 – Z7253

F11 – F169

F18 – F199

 

HIGH BLOOD PRESSURE, SCREENING IN ADULTS (This recommendation was replaced in 04/2021 by the Hypertension in adults Screening recommendation. Please see that recommendation for dates of service after April 2021.)

USPSTF Recommendation

The USPSTF recommends screening for high blood pressure in adults aged 18 and older. (Grade A)

 

This recommendation was restated in October 2015 to state:

The USPSTF recommends screening for high blood pressure in adults aged 18 years or older. The USPSTF recommends obtaining measurements outside of the clinical setting for diagnostic confirmation before starting treatment. (Grade A)

 

CPT/HCPCS Codes

CPT 99385 – 99387

CPT 99395 – 99397

CPT 93784 – 93790

 

ICD-9 Code

V81.1 — Screening for hypertension

 

ICD-10 Code

Z136

 

HIGH BLOOD PRESSURE, SCREENING IN INFANTS, CHILDREN & ADOLESCENTS

HRSA (Bright Futures) Recommendation

Infants and children with specific risk factors for high blood pressure should be screened up through age 2 1/2; blood pressure examination is included in the complete physical examination done routinely after 2 1/2.

 

CPT/HCPCS Codes

CPT 99381 – 99384

CPT 99391 – 99394

 

HIV pre-exposure prophylaxis for the prevention of HIV infection:

 

The USPSTF recommends that clinicians offer pre-exposure prophylaxis (PrEP) with effective antiretroviral therapy to persons who are at high risk of HIV acquisition.

 

Additional guidance received in 2021 regarding PrEP:

 

Clinicians should offer pre-exposure prophylaxis (PrEP) with effective antiretroviral therapy to persons who are not infected with HIV and who are at high risk of HIV acquisition. The USPSTF recommends the following services to be received prior to being prescribed antiretroviral medication as part of the determination of whether PrEP is appropriate as well as ongoing follow-up and monitoring:

 

• HIV testing at baseline and every three months while taking PrEP
• Hepatitis B and C testing
• Creatinine testing and calculated estimated creatinine clearance (eCrCL) or glomerular filtration rate (eGFR) to assess kidney function conducted both at baseline and periodically thereafter, consistent with CDC guidelines
• Pregnancy testing, both at baseline and periodically thereafter
• Sexually transmitted infection (STI) screening and counseling
• Adherence counseling

 

Applicable ICD 10 diagnosis codes: Z11.3, Z11.4, Z720.2, Z720.6, Z71.7, Z72.51, Z72.52, Z725.3, Z77.21, Z2981

Applicable CPT codes: 80047, 80048, 80053, 80069, 81025, 82565, 82570, 82540, 84702

 

All other benefits can be found under Hepatitis, B and C, Human Immunodeficiency (HIV) and Sexually transmitted infection (STI) screening and counseling categories.

 

Pre-exposure prophylaxis (PrEP) with effective antiretroviral therapy is a pharmacy benefit.

 

HIV screening: Adolescents and adults ages 15 to 65 years

 

The USPSTF recommends that clinicians screen for human immunodeficiency virus (HIV) in adolescents and adults ages 15 – 65 years. Younger adolescents and older adults who are at increased risk should also be screened. (Grade A)

The USPSTF recommends that clinicians screen all pregnant women for HIV, including those who present in labor who are untested and whose HIV status is unknown. (Grade A) 

 

HRSA (Bright Futures) Recommendation

Sexually active adolescents who are positive on risk questions should be screened for HIV.

 

CPT/HCPCS Codes

CPT 86703

CPT 87389

CPT 87390

HCPCS G0432

HCPCS G0433

HCPCS G0435

HCPCS S3645

 

ICD-9 Codes

V01.79

V22.0 – V24.2

 

ICD-10 Codes

Z114

Z206

Z20828

Z34 – Z3493

Z331

Z717

Z7251 – Z7253

O0900 – O0993

 

Hypertension in Adults: Screening: 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.

 

CPT:

Code with the appropriate evaluation and management code.

 

HYPOTHYROIDISM, SCREENING IN NEWBORNS

USPSTF Recommendation

The USPSTF recommends screening for congenital hypothyroidism in newborns. (Grade A)

 

HRSA (Bright Futures) Recommendation

This test is usually done prior to discharge from the hospital following birth of the infant.

 

CPT/HCPCS Code

CPT 84443 — Thyroid stimulating hormone (TSH)

 

ICD-9 Code

V77.0 — Screening for thyroid disorder

 

ICD-10 Code

Z1329

 

INTIMATE PARTNER VIOLENCE, SCREENING/COUNSELING OF WOMEN, ANNUALLY

USPSTF Recommendation

The USPSTF recommends that clinicians screen women of childbearing age for intimate partner violence, such as domestic violence, and provide or refer women who screen positive to intervention services. This recommendation applies to women who do not have signs or symptoms of abuse.

 

CPT/HCPCS Code

CPT 99401

*Codes 99402 – 99404 will require record review.

 

ICD-9 Code

V61.11 — Counseling for victim of spousal and partner abuse

 

ICD-10 Code

Z6911

 

IRON DEFICIENCY ANEMIA SCREENING IN PREGNANT WOMEN

USPSTF Recommendation

The USPSTF recommends routine screening for iron deficiency anemia in asymptomatic pregnant (Grade B).

 

CPT/HCPCS Codes

CPT 80055

CPT 80081

CPT 85013

CPT 85014

CPT 85018

 

ICD-9 Codes

V22.0 – V23.9

 

ICD-10 Codes

Z34 – Z3493

Z331

O0900 – O0993

 

LEAD SCREENING IN INFANTS CHILDREN AND THROUGH AGE 6

HRSA (Bright Futures) Recommendation

Begin screening at the 6-month well-child visit for children who are positive on risk screening questions. Continue as routine screening for children from high prevalence area and screen selectively children from low prevalence areas.

 

CPT/HCPCS Code

CPT 83655

 

LIPID (CHOLESTEROL), SCREENING

USPSTF Recommendations

The USPSTF strongly recommends screening men aged 35 and older for lipid disorders. (Grade A)

 

The USPSTF recommends screening men aged 20 to 35 for lipid disorders if they are at increased risk for coronary heart disease. (Grade B)

 

The USPSTF strongly recommends screening women aged 45 and older for lipid disorders if they are at increased risk for coronary heart disease. (Grade A)

 

The USPSTF recommends screening women aged 20 to 45 for lipid disorders if they are at increased risk for coronary heart disease. (Grade B)

 

HRSA (Bright Futures) Recommendation

Begin screening with lipid profile for children who test positive on risk screening questions beginning at age 2. Screening would not be repeated unless the child or adolescent’s risk factors changed. If the risk factors change, screening could be repeated at 4 years, 6 years, 8 years, 10 years, between 11 and 14 years, between 15 and 17 years and between 18 and 21 years.

 

CPT/HCPCS Code

CPT 80061

 

ICD-9 Code

V77.91 — Screening for lipoid disorders

 

ICD-10 Code

Z13220

 

LUNG CANCER SCREENING, ADULTS

USPSTF Recommendation 

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.

 (Grade B)

 

CPT/HCPCS Codes

71250 with modifier 52

S8032 (effective Oct. 1, 2014)

G0296 (effective Jan. 1, 2016)

G0297 (effective Jan. 1, 2016)

71271 (effective Jan. 1, 2021) 

 

ICD-9 Code

V76.0

 

ICD-10 Code

Z122

 

Newborn Bilirubin

Bright Futures recommends confirmation of initial bilirubin screening was accomplished, results verified and follow-up as appropriate are done.

 

CPT 82247 or 82248 during the first 28 days after birth indicate this service has been done.

 

NUTRITION (DIETARY) COUNSELING, ADULTS

USPSTF Recommendation

The USPSTF recommends offering or referring adults who are overweight or obese and have additional cardiovascular disease (CVD) risk factors to intensive behavior counseling interventions to promote a healthful diet and physical activity for CVD prevention. (Grade B)

 

The above verbiage was amended by the USPSTF 11/2020 to state:

 

The USPSTF recommends offering or referring adults with cardiovascular disease risk factors to behavioral counseling interventions to promote a healthy diet and physical activity.

 

CPT/HCPCS Codes

CPT 97802 – 97804

HCPCS G0270

HCPCS S9470

 

ICD-9 Code

V65.3 — Dietary surveillance and counseling

 

ICD-10 Code

Z713

 

OBESITY IN ADULTS AND CHILDREN 6 YEARS OR OLDER; SCREENING AND COUNSELING

USPSTF Recommendation

Effective June 2012:

The USPSTF recommends screening all adults for obesity. Clinicians should offer or refer patients with a body mass index (BMI) of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions. (Grade B)

 

Prior to June 2012:

The USPSTF recommends that clinicians screen all adult patients and children 6 years or older for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese individuals. For children clinicians should offer then or refer them to comprehensive, intensive behavioral interventions to promote improvement in weight status. (Grade B)

 

Recommendation updated in June of 2017:

 

Obesity screening: Childhood and adolescents:

 

The USPSTF recommends that clinicians screen for obesity in children and adolescents 6 years and older and offer or refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status.

Effective June 2024 the USPSTF verbiage has been updated to state:

High Body Mass Index in Children and Adolescents: Interventions: Children and Adolescents 6 Years or Older:

The USPSTF recommends that clinicians provide or refer children and adolescents 6 years or older with a high body mass index (BMI) (>95 percentile for age and sex) to comprehensive, intensive behavioral interventions.

 

HRSA (Bright Futures — Anticipatory Guidance)

Bright Futures identifies healthy weight promotion as 1 of 2 critical themes within the guidelines. Recommendations in Bright Futures are consistent with the Prevention and Prevention Plus stages outlined in the Expert Committee Recommendations regarding the Prevention, Assessment, and Treatment of Child Adolescent Overweight and Obesity. This recommendation applies to children age 6 and above.  

 

CPT/HCPCS Codes

CPT 99401

CPT 99402

HCPCS G0447

 

ICD-9 Code

V77.8 — Screening for obesity

 

ICD-10 Code

Z1389

 

OSTEOPOROSIS SCREENING IN WOMEN

USPSTF Recommendation

The USPSTF recommends screening for osteoporosis to prevent osteoporotic fractures in postmenopausal women younger than 65 years who are at increased risk of osteoporotic fracture as estimated by clinical risk assessment. (grade B)

 

The USPSTF recommends screening for osteoporosis to prevent osteoporotic fractures in women 65 years and older. (grade B)

 

CPT/HCPCS Code

CPT 77080

 

ICD-9 Code

V82.81 — Special screening for osteoporosis

 

ICD-10 Code

Z13820

 

Perinatal Depression: Counseling and Intervention

 

USPSTF Recommendation

The USPSTF recommends that clinicians provide or refer pregnant and postpartum persons who are at increased risk of perinatal depression to counseling interventions.

 

CPT Code:

 

96160 administration of patient-focused health risk assessment instrument (e.g., health hazard appraisal) with scoring and documentation, per standardized instrument

 

USE OF -33 MODIFIER IS MANDATORY

 

ICD-9 code

V79.0 screening for depression

 

ICD-10 code

Z1332 — Encounter for screening for maternal depression

 

PHENYLKETONURIA SCREENING IN NEWBORNS

USPSTF Recommendation

The USPSTF recommends screening for phenylketonuria (PKU) in newborns. (Grade A)

 

HRSA (Bright Futures) Recommendation

This test is usually done prior to discharge from the hospital following birth of the infant.

 

CPT/HCPCS Code

CPT 84030

 

ICD-9 Code:

V77.7 — Screening for other inborn errors of metabolism

 

ICD-10 Code

Z13228

 

PRE-ECLAMPSIA PREVENTION ASPIRIN

The USPSTF recommends the use of low-dose aspirin (81 mg/d) as preventive medication after 12 weeks of gestation in women who are at high risk for pre-eclampsia.

 

PRE-ECLAMPSIA SCREENING: BLOOD PRESSURE

 

April 2017 recommendation:

 

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

 

PSYCHOSOCIAL/BEHAVIORAL ASSESSMENT

Bright Futures recommendation that a psychosocial/behavioral assessment is completed that should be family-centered and may include an assessment of child social-emotional health, caregiver depression, and social determinants of health during preventive visits.

 

CPT 96127 — Brief emotional/behavioral assessment (e.g., depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument.

 

To indicate this service has been provided, CPT code 96127 should be filed in conjunction with the preventive visit codes: 99381 – 99384, 99391 – 99394, 99385 or 99395.

   

RH INCOMPATABILITY SCREENING

USPSTF Recommendations

The USPSTF strongly recommends Rh (D) blood typing and antibody testing for all pregnant women during their first visit for pregnancy-related care. (Grade A)

The USPSTF recommends repeated Rh (D) antibody testing for all unsensitized Rh (D)-negative women at 24 – 28 weeks' gestation, unless the biological father is known to be Rh (D)-negative. (Grade B)

 

CPT/HCPCS Codes

CPT 80055

CPT 80081

CPT 86901

 

ICD-9 Codes

V22.0 – V23.9 

 

ICD-10 Codes

Z34 – Z3493

Z331

O0900 – O0993

 

SCREENING FOR DIABETES MELLITUS AFTER PREGNANCY

HRSA recommends women with a history of gestational diabetes mellitus who are not currently pregnant and who have not previously been diagnosed with Type 2 diabetes mellitus should be screened for diabetes mellitus. Initial screening should ideally occur within the first year postpartum and can be conducted as early as 4 – 6 weeks postpartum. Women with a negative initial postpartum screening test result should be rescreened at least every 3 years for a minimum of 10 years after pregnancy.

 

CPT CODE

82951

 

ICD-9 CODE

V12.21

 

ICD-10 CODE

Z86.32

 

SCREENING FOR URINARY INCONTINENCE

HRSA recommends screening women for urinary incontinence annually.

 

CPT CODES

99401

1090f

Both codes are anticipated to be filed to demonstrate this screening has been done.

 

SEXUALLY TRANSMITTED INFECTIONS (STI’s); BEHAVIORAL COUNSELING TO PREVENT

USPSTF Recommendation

The USPSTF recommends behavioral counseling for all sexually active adolescents and for adults who are at increased risk for sexually transmitted infections (STIs).

 

CPT/HCPCS Codes

CPT 99401

CPT 99402

 

ICD-9 Codes

V65.44 — Human immunodeficiency virus counseling

V65.45 — Counseling on other sexually transmitted diseases

V69.2 — Problems related to high-risk sexual behavior

 

ICD-10 Codes

Z717

Z7189

Z7251 – Z7253

 

SKIN CANCER COUNSELING FOR PERSONS 6 – 24 YEARS

USPSTF Recommendation

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. (Grade B)

 

CPT/HCPCS Code

CPT 99401

 

ICD-9 Code

V65.49

 

ICD-10 Code

Z7189

  

SICKLE CELL SCREENING DISEASE, NEWBORN SCREENING

USPSTF Recommendation

The USPSTF recommends screening for sickle cell disease in newborns. (Grade A)

 

HRSA (Bright Futures) Recommendation

This test is usually done prior to discharge from the hospital following birth of the infant.

 

CPT/HCPCS Codes

CPT 83020

CPT 83021

 

ICD-9 Codes

V30 – V30.9

V78.2

 

ICD-10 Codes

Z38 – Z38.8  

Z130

 

STATIN PREVENTIVE MEDICATION:

The USPSTF recommends that adults without a history of cardiovascular disease (CVD) (i.e., symptomatic coronary artery disease or ischemic stroke) use a low- to moderate-dose statin for the prevention of CVD events and mortality when all of the following criteria are met: 1) they are ages 40 to 75 years; 2) they have 1 or more CVD risk factors (i.e., dyslipidemia, diabetes, hypertension, or smoking); and 3) they have a calculated 10-year risk of a cardiovascular event of 10% or greater. Identification of dyslipidemia and calculation of 10-year CVD event risk requires universal lipids screening in adults ages 40 to 75 years. (GRADE b)

Recommendation updated August, 2022 to read:

The USPSTF recommends that clinicians prescribe a statin for the primary prevention of CVD for adults aged 40 to 75 years who have 1 or more CVD risk factors (i.e., dyslipidemia, diabetes, hypertension, or smoking) and an estimated 10-year risk of a cardiovascular event of 10% or greater. Grade B

Covered medications include the following:

• Atorvastatin 10 mg, 20 mg
• Fluvastatin 20 mg, 40 mg
• Fluvastatin ER 80 mg
• Lovastatin 10 mg, 20 mg, 40 mg
• Pravastatin 10 mg, 20 mg, 40 mg, 80 mg
• Rosuvastatin 5 mg, 10 mg
• Simvastatin 5 mg, 10 mg, 20 mg, 40 mg

 

SYPHILIS SCREENING

USPSTF Recommendation

 

The USPSTF recommends screening for syphilis infection in persons who are at increased risk for infection.

 

The USPSTF recommends early, universal screening for syphilis infection during pregnancy; if an individual is not screened early in pregnancy, USPSTF recommends screening at the first available opportunity. 

 

HRSA (Bright Futures) Recommendation

Bright Futures recommends screening for syphilis in all adolescents who are sexually active and positive for high risk.

 

CPT/HCPCS Codes

CPT 80055

CPT 80081

CPT 86592

CPT 86780

 

ICD-9 Codes

V22.0 – V23.9

V69.2

V74.5 

 

ICD-10 Codes

Z202

Z34 – Z3493

Z331

Z113

O0900 – O0993

Z7251 – Z7253

 

TOBACCO USE, SCREENING, COUNSELING AND INTERVENTIONS

USPSTF Recommendation

The USPSTF recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products. (Grade A)

 

The USPSTF recommends that clinicians ask all pregnant women about tobacco use and provide augmented, pregnancy-tailored counseling for those who smoke. (Grade A)

 

The USPSTF recommends that clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use in school-aged children.

 

These recommendations were restated in September 2015 to state:

 

Tobacco use counseling and interventions: nonpregnant adults

• The USPSTF recommends that clinicians ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and U.S. Food and Drug Administration (FDA)-approved pharmacotherapy for cessation to adults who use tobacco. Grade A
• Tobacco use counseling: pregnant women The USPSTF recommends that clinicians ask all pregnant women about tobacco use, advise them to stop using tobacco, and provide behavioral interventions for cessation to pregnant women who use tobacco. Grade A

The recommendation related to school aged children and tobacco was not altered.

 

April 2020 update to verbiage states:

 

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.

 

HRSA (Bright Futures) Recommendation

Bright Futures recommends that health care professionals screen for tobacco use and tobacco smoke exposure, encourage tobacco use cessation, and provide tobacco use cessation strategies and resources at most visits for school-aged children and adolescents ages 5 years and older.

 

CPT/HCPCS Codes

CPT 99406

CPT 99407

 

ICD-9 Codes

305.1 — Tobacco dependence

649.01 – 649.04 — Smoking complicating pregnancy

V15.82 — History of tobacco use

V15.89 — Other specified personal history presenting hazards to health, Other

 

ICD-10 Codes

F17200

O99300 – O99335

Z87891

Z779

Z9289

 

TUBERCUOLOSIS SCREENING: ADULT

The USPSTF recommends screening for latent tuberculosis infection in populations at increased risk.

 

CPT CODES

86480

86580

 

ICD-9 CODE

V741 — Screening examination for pulmonary tuberculosis

 

ICD-10 CODE

Z11.1 — Encounter for screening of respiratory tuberculosis

 

TUBERCULOSIS SCREENING PEDIATRIC

HRSA (Bright Futures) recommendation:

 

Screening for risk factors that would indicate high risk of tuberculosis should be performed at one month, 6 months, 12 months and then annually. If determined to be at high risk, testing should be performed.

 

CPT CODES:

86480

86580

 

ICD-9 CODE:

V741 — Screening examination for pulmonary tuberculosis

 

ICD-10 CODE:

Z11.1 — Encounter for screening of respiratory tuberculosis

 

Unhealthy Alcohol Use: Adults

 

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.

 

CPT/HCPCS Codes
CPT 99408
HCPCS G0396
HCPCS G0443

ICD-9 Codes
V79.1 Screening for alcoholism

ICD-10 Codes

Z1389   

Unhealthy Drug Use: Screening Adults Age 18 or Older: 

The USPSTF recommends screening by asking questions about unhealthy drug use in adults ages 18 years or older. Screening should be implemented when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred. (Screening refers to asking questions about unhealthy drug use, not testing biological specimens.) 

VISUAL IMPAIRMENT, SCREENING IN CHILDREN

USPSTF Recommendation

The USPSTF recommends vision screening for all children at least once between the ages of 3 and 5 years by a non-eye care professional, to detect the presence of amblyopia or its risk factors (Grade B)

 

HRSA (Bright Futures) Recommendation

Selective screening of newborn, infants, and children through age 2, to assess for abnormal funduscopic examination, particularly if premature or other risk conditions.

 

CPT/HCPS Codes

CPT 99173

CPT 99174

CPT 99177

 

For members 6 years old and older, instrument-based ocular screening will be considered NOT MEDICALLY NECESSARY.

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

Reference 

1. Internet Citation: USPSTF A and B Recommendations, U.S. Preventive Services Task Force. August 2019  http://www.uspreventiveservicestaskforce.org/Page/Name/upstf-a-and-b-recommendations/ 

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

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

History From 2024 Forward     

05/01/2026	Interim review, adding CPT codes 77062 and 77063 to breast cancer screening. Also removing CPT codes 99401 and 99402 and adding HCPCS code S9443 to breastfeeding counseling recommendation. No other changes.
01/14/2026	Interim review, removing 0500T (effective 1/1/25) and adding CPT 87626 (effective 1/1/25) to cervical cancer screening.
01/01/2026	Annual review, no change to policy intent.
01/02/2025	Annual review, no change to policy intent.
11/01/2024	Added DX Z2981 to PrEp Section. No other changes made.
06/26/2024	Interim review, effective 06/2024 the USPSTF recommends that clinicians provide or refer children and adolescents 6 years or older with a high body mass index (BMI) (> 95 percentile for age and sex) to comprehensive, intensive behavioral interventions.
05/29/2024	Interim Review, effective 07012024 the coverage criteria for cardiovascular prevention related to low asprin use terminates as USPSTF decrease this recommendation to a C/D recommendation.
01/01/2024	NEW POLICY