Women's Preventive Services - CAM 094HB
Description
The Federal Patient Protection and Preventive Care Act (PPACA) was passed by Congress and signed into law by the president in March 2010. The preventive services component of the law became effective Sept. 23, 2010. A component of the law was a requirement that all “non-grandfathered” health insurance plans are required to cover those preventive medicine services given an “A” or “B” recommendation by the U.S. Preventive Services Task Force (USPSTF).
Plans are not required to provide coverage for the preventive services if they are delivered by out-of-network providers.
Task Force recommendations are graded on a five-point scale (A – E), reflecting the strength of evidence in support of the intervention. Grade A: There is good evidence to support the recommendation that the condition be specifically considered in a periodic health examination. Grade B: There is fair evidence to support the recommendation that the condition be specifically considered in a periodic health examination. Grade C: There is insufficient evidence to recommend for or against the inclusion of the condition in a periodic health examination, but recommendations may be made on other grounds. Grade D: There is fair evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination. Grade E: There is good evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.
Those preventive medicine services listed as Grade A & B recommendations are covered without cost sharing (i.e., deductible, coinsurance or copayment) by health plans for appropriate preventive care services provided by an in-network provider. If the primary purpose for the office visit is for other than Grade A or B USPSTF preventive care services, deductible, coinsurance or copayment may be applied.
Services are typically included as part of a normal wellness visit; the appropriate office visit code should be used. Evaluation and Management codes for preventive services 99381 – 99397 will always be considered preventive. CPT codes 99401 – 99404, when used to designate a preventive service, must have the applicable wellness/preventive diagnosis code as the primary reason for the visit.
When the primary purpose of the service is the delivery of an evidence-based service in accordance with a U.S. Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’.
The correct coding as listed for both ICD-9 and CPT or HCPCS codes in this summary is also required along with Modifier 33. CPT Codes Copyright © 2011 American Medical Association.
Subject to change as regulations and further clarifications are received.
NOTE: THIS POLICY APPLIES ONLY TO NON-GRANDFATHERED PLANS.
Policy:
BACTERIURIA, SCREENING IN PREGNANT WOMEN
USPSTF Recommendation
The USPSTF recommends that clinicians engage in shared, informed decision making with women who are at increased risk for breast cancer about medications to reduce their risk. For women who are at increased risk for breast cancer and at low risk for adverse medication effects, clinicians should offer to prescribe risk-reducing medications, such as tamoxifen or raloxifene. (Grade B) Examples of screening tools include, but are not limited to Ontario Family Health Assessment tool, Manchester Scoring System, Referral Screening tool or the Pedigree Assessment tool.
NOTE: Effective 01012023 FDA approved digital web based applications for contraception ONLY will be considered medically necessary. As there is no coding specific to those applications, they will be represented by the following codes: A9291 V25.9 and Z30.9
NOTE: For all over the counter or self purchased contraceptives, the member will file the request for reimbursement including the receipt of their payment.
00851 | Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy. |
11976 | Removal, implantable contraceptive capsules |
11980 | Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets beneath the skin) |
11981 | Insertion, non-biodegradable drug delivery implant (e.g., Implanon) |
11982 | Removal, non-biodegradable drug delivery implant |
11983 | Removal with reinsertion, non-biodegradable drug delivery implant |
57170 | Diaphragm or cervical cap fitting with instructions |
58300 | Insertion of intrauterine device (IUD) |
58301 | Removal of intrauterine device (IUD) |
58340 | CATHETERIZATION AND INTRODUCTION OF SALINE OR CONTRAST MATERIAL FOR SALINE INFUSION SONOHYSTEROGRAPHY (SIS) OR HYSTEROSALPINGOGRAPHY |
58565 | Hysteroscopy, surgical, with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants |
58600 | Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral |
58605 | Ligation or transection of fallopian tube(s), abdominal or vaginal approach, postpartum, unilateral or bilateral, during same hospitalization |
58611 | Ligation or transection of fallopian tube(s) when done at time of cesarean or intra-abdominal surgery |
58615 | Occlusion of fallopian tube(s), by device (e.g., band, clip, Falope ring) vaginal or suprapubic approach |
58661 | Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy). If filed with diagnosis Z30.2 |
58670 | LAPAROSCOPY, SURGICAL; WITH FULGURATION OF OVIDUCTS (WITH OR WITHOUT TRANSECTION). If filed with diagnosis Z30.2. |
58671 | Laparoscopy, surgical, with occlusion of oviducts by device (e.g., band, clip or Falope ring) |
58700 | ***SALPINGECTOMY, COMPLETE OR PARTIAL, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE) |
96372 | Therapeutic, Prophylactic or Diagnostic injection (specify substance or drug); subcutaneous or intramuscular |
A4261 | Cervical cap for contraceptive use |
A4264 | Permanent implantable contraceptive intratubal occlusion device(s) and delivery system |
A4266 | DIAPHRAGM FOR CONTRACEPTIVE USE |
A4267 | Contraceptive supply, condom, male, each to the grid of contraceptives. |
A4268 | CONTRACEPTIVE SUPPLY, CONDOM, FEMALE, EACH |
A4269 | CONTRACEPTIVE SUPPLY, SPERMICIDE (E.G., FOAM, GEL), EACH |
J1050 | Medroxyprogesterone acetate, 1 mg |
J7296 | Levonorgestrel-releasing intrauterine contraceptive system (Kyleena), 19.5 mg |
J7297 | Levonorgestrel-releasing intrauterine contraceptive system, 52 mg, 3 year duration |
J7298 | Levonorgestrel-releasing intrauterine contraceptive system, 52 mg, 5 year duration |
J7300 | Intrauterine copper contraceptive |
J7302 (code deleted 1/1/2016) | Levonorgestrel-releasing intrauterine contraceptive system (e.g., Mirena) |
J7303 | Contraceptive supply, hormone containing vaginal ring, each |
J7304 | Contraceptive supply, hormone containing patch, each |
J7306 | Levonorgestrel (contraceptive) implant system, including implants and supplies |
J7307 | Etonogestrel (contraceptive) implant system, including implant and supplies |
Q9984 (code deleted 1/1/2018) | Kyleena™ (levonorgestrel-releasing intrauterine system) 19.5 mg |
S4981 | Insertion of levonorgestrel-releasing intrauterine system (e.g., Mirena) |
S4989 | Contraceptive intrauterine device (e.g., Progestasert IUD) |
S4993 | CONTRACEPTIVE PILLS FOR BIRTH CONTROL |
Diagnosis codes: | |
V15.7 | PERSONAL HISTORY OF CONTRACEPTION, PRESENTING HAZARDS TO HEALTH |
V25.01 | Prescription of oral contraceptives |
V25.02 | Initiation of other contraceptive measures. |
V25.03 | Encounter for emergency contraceptive counseling and prescription. |
V25.04 | Counseling and instruction in natural family planning to avoid pregnancy |
V25.09 | Other family planning advice |
V25.11 | Encounter for insertion of intrauterine contraceptive device |
V25.12 | Encounter for removal of intrauterine contraceptive device |
V25.13 | Encounter for removal and reinsertion of intrauterine contraceptive device. |
V25.2 | Sterilization |
V25.40 | CONTRACEPTIVE SURVEILLANCE, UNSPECIFIED |
V25.41 | Contraceptive pill |
V25.42 | Intrauterine contraceptive device |
V25.43 | Implantable subdermal contraceptive |
V25.49 | Other contraceptive method |
V25.5 | Insertion of implantable subdermal contraceptive |
V25.8 | OTHER SPECIFIED CONTRACEPTIVE MANAGEMENT |
V25.9 | UNSPECIFIED CONTRACEPTIVE MANAGEMENT |
V26.41 | PROCREATIVE COUNSELING AND ADVICE USING NATURAL FAMILY PLANNING |
V26.49 | OTHER PROCREATIVE MANAGEMENT COUNSELING AND ADVICE |
V26.51 | TUBAL LIGATION STATUS |
V45.51 | PRESENCE OF INTRAUTERINE CONTRACEPTIVE DEVICE |
V45.52 | PRESENCE OF SUBDERMAL CONTRACEPTIVE IMPLANT |
V45.59 | PRESENCE OF OTHER CONTRACEPTIVE DEVICE |
Z30.2 | Encounter for sterilization |
996.32 | Mechanical complication due to intrauterine contraceptive device |
ICD-9 procedures: | |
66.21 | BILATERAL ENDOSCOPIC LIGATION AND CRUSHING OF FALLOPIAN TUBES |
66.22 | BILATERAL ENDOSCOPIC LIGATION AND DIVISION OF FALLOPIAN TUBES |
66.29 | OTHER BILATERAL ENDOSCOPIC DESTRUCTION OR OCCLUSION OF FALLOPIAN TUBES |
66.31 | OTHER BILATERAL LIGATION AND CRUSHING OF FALLOPIAN TUBES |
66.32 | OTHER BILATERAL LIGATION AND DIVISION OF FALLOPIAN TUBES |
66.39 | OTHER BILATERAL DESTRUCTION OR OCCLUSION OF FALLOPIAN TUBES |
66.51 | REMOVAL OF BOTH FALLOPIAN TUBES AT SAME OPERATIVE EPISODE |
66.52 | REMOVAL OF REMAINING FALLOPIAN TUBE |
66.92 | UNILATERAL DESTRUCTION OR OCCLUSION OF FALLOPIAN TUBE |
69.7 | INSERTION OF INTRAUTERINE CONTRACEPTIVE DEVICE |
97.71 | REMOVAL OF INTRAUTERINE CONTRACEPTIVE DEVICE |
ICD-10 Codes | |
Z920 |
Personal History of contraception |
Z30018 |
Encounter for initial prescription of other contraceptives |
Z30012 | Encounter for prescription of emergency contraception |
Z3009 | Encounter for other general counseling and advice on contraception |
Z3002 | Counseling and instruction in natural family planning to avoid pregnancy |
Z30430 | Encounter for insertion of intrauterine contraceptive device |
Z30432 | Encounter for removal of intrauterine contraceptive device |
Z302 | Encounter for sterilization |
Z3041 | Encounter for surveillance of contraceptive pills |
Z30431 | Encounter for routine checking of intrauterine contraceptive device |
Z3049 | Encounter for surveillance of other contraceptives |
Z308 | Encounter for other contraceptive management |
Z309 | Encounter for contraceptive management, unspecified |
Z3161 | Procreative counseling and advice using natural family planning |
Z3169 | Encounter for other general counseling and advice on procreation |
Z9851 | Tubal ligation status |
Z975 | Presence of (intrauterine) contraceptive device |
T8339XA | Other mechanical complication of intrauterine contraceptive device, initial encounter |
ICD-10 Procedures | |
0UPD7HZ | Removal of Contraceptive Device from Uterus and Cervix, Via Natural or Artificial Opening |
0UPD8HZ | Removal of Contraceptive Device from Uterus and Cervix, Via Natural or Artificial Opening Endoscopic |
0UH97HZ | Insertion of Contraceptive Device into Uterus, Via Natural or Artificial Opening |
0UH98HZ | Insertion of Contraceptive Device into Uterus, Via Natural or Artificial Opening Endoscopic |
0UHC7HZ | Insertion of Contraceptive Device into Cervix, Via Natural or Artificial Opening |
0UHC8HZ | Insertion of Contraceptive Device into Cervix, Via Natural or Artificial Opening Endoscopic |
0U550ZZ | Destruction of Right Fallopian Tube, Open Approach |
0U553ZZ | Destruction of Right Fallopian Tube, Percutaneous Approach |
0U554ZZ | Destruction of Right Fallopian Tube, Percutaneous Endoscopic Approach |
0U557ZZ | Destruction of Right Fallopian Tube, Via Natural or Artificial Opening |
0U558ZZ | Destruction of Right Fallopian Tube, Via Natural or Artificial Opening Endoscopic |
0U560ZZ | Destruction of Left Fallopian Tube, Open Approach |
0U563ZZ | Destruction of Left Fallopian Tube, Percutaneous Approach |
0U564ZZ | Destruction of Left Fallopian Tube, Percutaneous Endoscopic Approach |
0U567ZZ | Destruction of Left Fallopian Tube, Via Natural or Artificial Opening |
0U568ZZ | Destruction of Left Fallopian Tube, Via Natural or Artificial Opening Endoscopic |
0UL50CZ | Occlusion of Right Fallopian Tube with Extraluminal Device, Open Approach |
0UL50DZ | Occlusion of Right Fallopian Tube with Intraluminal Device, Open Approach |
0UL50ZZ | Occlusion of Right Fallopian Tube, Open Approach |
0UL53CZ | Occlusion of Right Fallopian Tube with Extraluminal Device, Percutaneous Approach |
0UL53DZ | Occlusion of Right Fallopian Tube with Intraluminal Device, Percutaneous Approach |
0UL53ZZ | Occlusion of Right Fallopian Tube, Percutaneous Approach |
0UL54CZ | Occlusion of Right Fallopian Tube with Extraluminal Device, Percutaneous Endoscopic Approach |
0UL54DZ | Occlusion of Right Fallopian Tube with Intraluminal Device, Percutaneous Endoscopic Approach |
0UL54ZZ | Occlusion of Right Fallopian Tube, Percutaneous Endoscopic Approach |
0UL57DZ | Occlusion of Right Fallopian Tube with Intraluminal Device, Via Natural or Artificial Opening |
0UL57ZZ | Occlusion of Right Fallopian Tube, Via Natural or Artificial Opening |
0UL58DZ | Occlusion of Right Fallopian Tube with Intraluminal Device, Via Natural or Artificial Opening Endoscopic |
0UL58ZZ | Occlusion of Right Fallopian Tube, Via Natural or Artificial Opening Endoscopic |
0UL60CZ | Occlusion of Left Fallopian Tube with Extraluminal Device, Open Approach |
0UL60DZ | Occlusion of Left Fallopian Tube with Intraluminal Device, Open Approach |
0UL60ZZ | Occlusion of Left Fallopian Tube, Open Approach |
0UL63CZ | Occlusion of Left Fallopian Tube with Extraluminal Device, Percutaneous Approach |
0UL63DZ | Occlusion of Left Fallopian Tube with Intraluminal Device, Percutaneous Approach |
0UL63ZZ | Occlusion of Left Fallopian Tube, Percutaneous Approach |
0UL64CZ | Occlusion of Left Fallopian Tube with Extraluminal Device, Percutaneous Endoscopic Approach |
0UL64DZ | Occlusion of Left Fallopian Tube with Intraluminal Device, Percutaneous Endoscopic Approach |
0UL64ZZ | Occlusion of Left Fallopian Tube, Percutaneous Endoscopic Approach |
0UL67DZ | Occlusion of Left Fallopian Tube with Intraluminal Device, Via Natural or Artificial Opening |
0UL67ZZ | Occlusion of Left Fallopian Tube, Via Natural or Artificial Opening |
0UL68DZ | Occlusion of Left Fallopian Tube with Intraluminal Device, Via Natural or Artificial Opening Endoscopic |
0UL68ZZ | Occlusion of Left Fallopian Tube, Via Natural or Artificial Opening Endoscopic |
0UT50ZZ | Resection of Right Fallopian Tube, Open Approach |
0UT54ZZ | Resection of Right Fallopian Tube, Percutaneous Endoscopic Approach |
0UT57ZZ | Resection of Right Fallopian Tube, Via Natural or Artificial Opening |
0UT58ZZ | Resection of Right Fallopian Tube, Via Natural or Artificial Opening Endoscopic |
0UT5FZZ | Resection of Right Fallopian Tube, Via Natural or Artificial Opening With Percutaneous Endoscopic Assistance |
0UT60ZZ | Resection of Left Fallopian Tube, Open Approach |
0UT64ZZ | Resection of Left Fallopian Tube, Percutaneous Endoscopic Approach |
0UT67ZZ | Resection of Left Fallopian Tube, Via Natural or Artificial Opening |
0UT68ZZ | Resection of Left Fallopian Tube, Via Natural or Artificial Opening Endoscopic |
0UT6FZZ | Resection of Left Fallopian Tube, Via Natural or Artificial Opening With Percutaneous Endoscopic Assistance |
0UT70ZZ | Resection of Bilateral Fallopian Tubes, Open Approach |
0UT74ZZ | Resection of Bilateral Fallopian Tubes, Percutaneous Endoscopic Approach |
0UT77ZZ | Resection of Bilateral Fallopian Tubes, Via Natural or Artificial Opening |
0UT78ZZ | Resection of Bilateral Fallopian Tubes, Via Natural or Artificial Opening Endoscopic |
0UT7FZZ | Resection of Bilateral Fallopian Tubes, Via Natural or Artificial Opening With Percutaneous Endoscopic Assistance |
0U570ZZ | Destruction of Bilateral Fallopian Tubes, Open Approach |
0U573ZZ | Destruction of Bilateral Fallopian Tubes, Percutaneous Approach |
0U577ZZ | Destruction of Bilateral Fallopian Tubes, Via Natural or Artificial Opening |
0UL70CZ | Occlusion of Bilateral Fallopian Tubes with Extraluminal Device, Open Approach |
0UL70DZ | Occlusion of Bilateral Fallopian Tubes with Intraluminal Device, Open Approach |
0UL70ZZ | Occlusion of Bilateral Fallopian Tubes, Open Approach |
0UL73CZ | Occlusion of Bilateral Fallopian Tubes with Extraluminal Device, Percutaneous Approach |
0UL73DZ | Occlusion of Bilateral Fallopian Tubes with Intraluminal Device, Percutaneous Approach |
0UL73ZZ | Occlusion of Bilateral Fallopian Tubes, Percutaneous Approach |
0UL77DZ | Occlusion of Bilateral Fallopian Tubes with Intraluminal Device, Via Natural or Artificial Opening |
0UL77ZZ | Occlusion of Bilateral Fallopian Tubes, Via Natural or Artificial Opening |
0UL70ZZ | Occlusion of Bilateral Fallopian Tubes, Open Approach |
0UL73ZZ | Occlusion of Bilateral Fallopian Tubes, Percutaneous Approach |
0UL77ZZ | Occlusion of Bilateral Fallopian Tubes, Via Natural or Artificial Opening |
0U574ZZ | Destruction of Bilateral Fallopian Tubes, Percutaneous Endoscopic Approach |
0U578ZZ | Destruction of Bilateral Fallopian Tubes, Via Natural or Artificial Opening Endoscopic |
0UL74CZ | Occlusion of Bilateral Fallopian Tubes with Extraluminal Device, Percutaneous Endoscopic Approach |
0UL74DZ | Occlusion of Bilateral Fallopian Tubes with Intraluminal Device, Percutaneous Endoscopic Approach |
0UL74ZZ | Occlusion of Bilateral Fallopian Tubes, Percutaneous Endoscopic Approach |
0UL78DZ | Destruction of Bilateral Fallopian Tubes, Percutaneous Endoscopic Approach |
0UL78ZZ | Destruction of Bilateral Fallopian Tubes, Via Natural or Artificial Opening Endoscopic |
0UL74CZ | Occlusion of Bilateral Fallopian Tubes with Extraluminal Device, Percutaneous Endoscopic Approach |
0UL74DZ | Occlusion of Bilateral Fallopian Tubes with Intraluminal Device, Percutaneous Endoscopic Approach |
0UL74ZZ | Occlusion of Bilateral Fallopian Tubes, Percutaneous Endoscopic Approach |
0UL78DZ | Occlusion of Bilateral Fallopian Tubes with Intraluminal Device, Via Natural or Artificial Opening Endoscopic |
0UL78ZZ | Occlusion of Bilateral Fallopian Tubes, Via Natural or Artificial Opening Endoscopic |
0UL74ZZ | Occlusion of Bilateral Fallopian Tubes, Percutaneous Endoscopic Approach |
0UL78ZZ | Occlusion of Bilateral Fallopian Tubes, Via Natural or Artificial Opening Endoscopic |
Effective August 2023:
The USPSTF recommends that all persons planning to or who could become pregnant take a daily supplement containing 0.4 – 0.8 mg (400 – 800mcg) of folic acid.
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)
Gynecological:
S0610 ANNUAL GYNECOLOGICAL EXAMINATION, NEW PATIENT
S0612 ANNUAL GYNECOLOGICAL EXAMINATION, ESTABLISHED PATIENT
S0613 ANNUAL GYNECOLOGICAL EXAMINATION; CLINICAL BREAST EXAMINATION WITHOUT PELVIC EVALUATION
New Patient:
99384 (Age 12 – 17) INITIAL COMPREHENSIVE PREVENTIVE MEDICINE EVALUATION AND MANAGEMENT
99385 (Age 18 – 39) INITIAL COMPREHENSIVE PREVENTIVE MEDICINE EVALUATION AND MANAGEMENT
99386 (Age 40 – 64) INITIAL COMPREHENSIVE PREVENTIVE MEDICINE EVALUATION AND MANAGEMENT
99387 (Age 65 year and older) INITIAL COMPREHENSIVE PREVENTIVE MEDICINE EVALUATION AND MANAGEMENT
Established Patient:
99394 (Age 12 – 17) PERIODIC COMPREHENSIVE PREVENTIVE MEDICINE REEVALUATION AND MANAGEMENT
99395 (Age 18 – 39) PERIODIC COMPREHENSIVE PREVENTIVE MEDICINE REEVALUATION AND MANAGEMENT
99396 (Age 40 – 64) PERIODIC COMPREHENSIVE PREVENTIVE MEDICINE REEVALUATION AND MANAGEMENT
99397 (Age 65 years and older) PERIODIC COMPREHENSIVE PREVENTIVE MEDICINE REEVALUATION AND MANAGEMENT
Annual Wellness Visit:
G0438 ANNUAL WELLNESS VISIT; INCLUDES A PERSONALIZED PREVENTION PLAN
G0439 ANNUAL WELLNESS VISIT, INCLUDES A PERSONALIZED PREVENTION PLAN
S5190 WELLNESS ASSESSMENT, PERFORMED BY NON-PHYSICIAN
99459 is an add on code effective 01012024 to reflect the work of a pelvic examination and should be filed in addition to the primary procedure.
ICD-9 Codes:
V72.3 Gynecological examination
V72.31 Routine gynecological examination
ICD-10 Code:
Z01419
- Internet Citation: USPSTF A and B Recommendations, U.S. Preventive Services Task Force. October 2014 http://www.uspreventiveservicestaskforce.org/Page/Name/upstf-a-and-b-recommendations/
This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.
"Current Procedural Terminology © American Medical Association. All Rights Reserved"
History From 2024 Forward
01012024 NEW POLICY