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CurrentAlaska MedicaidPolicy N/A

Adult Preventive Services Coverage Chart — Coverage Criteria

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Chart of covered adult preventive services for Alaska Medicaid including required procedure and ICD-10-CM screening codes, age/gender applicability, and billable status for providers submitting preventive service claims.

Policy Summary

PayerAlaska Medicaid

PolicyAdult Preventive Services Coverage Chart — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionInclude the applicable procedure codes and screening ICD-10-CM codes from the chart when submitting preventive service claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

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Multiplepreventive service categories

Includes CPT/HCPCS/otherprocedure and screening codes listed

Providedage/gender fields present

Covered Preventive Services — Criteria

General coverage by service

Covered preventive services where codes and age/gender applicability are specified in the chart.

Colorectal cancer screening (average risk): Covered when procedure codes 82270, G0328, G0120, G0121, G0105, or G0104 are billed with screening ICD-10-CM code(s) Z12.10, Z12.11, Z12.12, or Z12.13.age >= 45 years for average risk

Separately billable: N/A

Lung cancer screening

Services with additional administrative requirement.

Lung cancer screening: Covered when G0296 (counseling visit) and 71271 (low dose CT for lung cancer screening) are billed with screening ICD-10-CM code Z12.2.prior authorization required

Policy Summary

PayerAlaska Medicaid

PolicyAdult Preventive Services Coverage Chart — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionInclude the applicable procedure codes and screening ICD-10-CM codes from the chart when submitting preventive service claims.

SourceLink

On This Page

Mammography and BRCA testing

Breast cancer screening specifics.

Mammography screening: Covered when 77067 is billed with screening ICD-10-CM code Z12.31; high-risk associated ICD-10-CM codes N60.89, Z80.3, Z80.41, Z85.3, Z86.000, and R92.2 are listed for some indications.age >= 35 years for average risk

Separately billable: N/A

BRCA testing: Covered when BRCA procedure codes 81162-81167, 81212, or 81215-81217 are billed with screening ICD-10-CM code(s) Z13.71 or Z13.79.Applicable gender: Female

Separately billable: N/A

STI and viral hepatitis screening

Infectious disease screening.

Syphilis: Covered when serology procedure codes 86592, 86593, or 86780 are billed with screening ICD-10-CM code Z11.3.none

Separately billable: Yes

Chlamydia/Gonorrhea: Covered when laboratory procedure codes (e.g., 86631, 86632, 87110, 87270, 87320, 87490-87492, 87810, 87590-87592) are billed with screening ICD-10-CM code(s) Z11.3 or Z11.8.none

Separately billable: Yes

Hepatitis B/C: Covered when listed hepatitis testing procedure codes (86704, 86706, 87340, 87341, 87516, 87517 for Hep B; 86803, 87520-87522 for Hep C) are billed with screening ICD-10-CM code Z11.59.none

Separately billable: Yes

HIV and latent tuberculosis: Covered when HIV screening procedure codes (e.g., 86689, 86701, 86703, 87389-87391, 87534-87538) are billed with Z11.4, or when tuberculin test 86580 is billed with Z11.1.none

Separately billable: Yes

Depression, anxiety, alcohol/substance use screening and counseling

Behavioral health and substance use screening and counseling.

Depression screening: Covered when 96127 is billed with screening ICD-10-CM code Z13.31.none

Separately billable: Yes

Anxiety screening: Covered when anxiety screening is performed (as listed: billed under annual/preventive codes 99385-99387 or 99395-99397) with ICD-10-CM code Z13.39 as indicated.none

Separately billable: No

Unhealthy alcohol use screening and counseling: Covered when alcohol/substance use screening procedure codes 99408 or 99409 are billed with ICD-10-CM Z13.39; unhealthy alcohol use counseling is covered when G0443 is billed with Z71.41 and associated alcohol-related diagnosis codes F10.1-F10.19 or F10.9-F10.99 where specified.none

Separately billable: Yes

Procedure and Screening Codes

Annual Wellness ExamsmixedCovered

99385-99387	Annual wellness exam - New
99395-99397	Annual wellness exam - Established
Z00.00	General adult medical examination without abnormal findings
Z00.01	General adult medical examination with abnormal findings
Z01.411	Gynecological exam pelvic and clinical breast exam
Z01.419	Gynecological exam pelvic exam without further specification

Colorectal CancermixedCovered

82270	gFOBT
G0328	FIT
G0120	Colonoscopy
G0121	Colonoscopy/Avg
G0105	Colonoscopy/High risk
G0104	Sigmoidoscopy
Z12.10	Encounter for screening for malignant neoplasm of stomach
Z12.11	Encounter for screening for malignant neoplasm of colon
Z12.12	Encounter for screening for malignant neoplasm of rectum
Z12.13	Encounter for screening for malignant neoplasm of intestine

Breast cancer screening (mammography)mixedCovered

77067	Diagnostic digital breast tomosynthesis or mammography (screening mammography)
Z12.31	Encounter for screening mammogram for malignant neoplasm of breast
N60.89	Other specified Benign mammary dysplasia
Z80.3	Family history of malignant neoplasm of breast
Z80.41	Family history of malignant neoplasm of breast (female)
Z85.3	Personal history of malignant neoplasm of breast
Z86.000	Personal history of in situ carcinoma of breast
R92.2	Abnormal findings on diagnostic imaging of breast

Breast cancer preventive testing (BRCA)mixedCovered

81162-81167	BRCA1/BRCA2 full sequence analysis and variants
81212	BRCA1 large rearrangement
81215-81217	BRCA2 large rearrangement and related testing
Z13.71	Encounter for genetic screening for BRCA1 and BRCA2
Z13.79	Encounter for other genetic screening

Cervical cancer screening (Pap-smear)mixedCovered

88141-88143	Cytopathology, cervical or vaginal (Pap) smears
88147-88148	Cytopathology Pap smear codes
88150-88153	Cytopathology, ThinPrep and other codes
88155	Cytopathology reflex HPV testing
88160-88162	Cervical/or vaginal cytology codes
88164-88167	Additional cytology codes
88172-88175	Cytopathology automated screening
88177	Cytopathology ancillary testing
Z01.411	Gynecological exam pelvic and clinical breast exam
Z01.419	Gynecological exam pelvic exam without further specification

1–10 of 12

1/2

Cervical cancer screening (HPV)mixedCovered

87624	HPV testing
Z11.51	Encounter for screening for human papillomavirus (HPV)

Lung cancer screeningmixedCovered

G0296	Counseling visit to discuss need for lung cancer screening
71271	CT low dose for lung cancer screening
Z12.2	Encounter for screening for malignant neoplasm of respiratory organs

Tobacco cessation counseling / lung cancer preventive counselingmixedCovered

99406	Smoking and tobacco use cessation counseling (intermediate)
99407	Smoking and tobacco use cessation counseling (intensive)
Z71.6	Tobacco abuse counseling
F17.200	Nicotine dependence
F17.202-F17.299	Other nicotine dependence codes range
O99.330-O99.335	Pregnant tobacco use complicating pregnancy codes range

Abdominal aortic aneurysm screeningmixedCovered

76706	Ultrasound, abdominal aorta for aneurysm
Z13.6	Encounter for screening for cardiovascular disorders
F17.210-F17.219	Nicotine dependence codes (required for AAA in chart)
Z87.891	Personal history of nicotine dependence - related

Obesity prevention / counseling and related required codesmixedCovered

99401-99404	Preventive medicine counseling codes
99411-99412	Group counseling codes
Z71.3	Dietary counseling and surveillance
Z71.82	Exercise counseling
E08.00-E13.9	Diabetes mellitus range (listed as required codes for obesity prevention)
E66.01-E66.2	Obesity codes range
E66.8-E66.9	Other obesity codes
E78.0-E78.5	Disorders of lipoprotein metabolism range
I10-I15.9	Hypertensive diseases range
R73.01-R73.09	Elevated glucose and related codes range

1–10 of 11

1/2

Prediabetes and Type 2 Diabetes screening; obstetric bacteriuriamixedCovered

81000, 81002, 81005, 82947, 82948, 82950-82952, 83036	Urinalysis and glucose/lab codes used for diabetes screening and obstetric bacteriuria screening
Z13.1	Encounter for screening for diabetes mellitus

Osteoporosis screeningmixedCovered

76977, 77078, 77080, 77081, 77085, 77086	Bone density (DXA) and related imaging codes
Z13.820	Encounter for screening for osteoporosis

Infectious disease screening (Syphilis, Chlamydia/Gonorrhea, Hep B/C)mixedCovered

86592, 86593, 86780	Syphilis serology testing
Z11.3	Encounter for screening for venereal diseases
86631, 86632, 87110, 87270, 87320, 87490, 87491, 87492, 87810, 87590, 87591, 87592	Chlamydia and gonorrhea testing codes
Z11.59	Encounter for screening for other infectious and parasitic diseases (Hep B/C)
86704, 86706, 87340, 87341, 87516, 87517	Hepatitis B testing codes
86803, 87520-87522	Hepatitis C testing codes

HIV and latent tuberculosis screeningmixedCovered

86689, 86701, 86703, 87389, 87390, 87391, 87534-87538	HIV screening codes (antibody/antigen)
Z11.4	Encounter for screening for human immunodeficiency virus [HIV]
86580	TB screening (tuberculin skin test)
Z11.1	Encounter for screening for infectious and parasitic diseases (tuberculosis)

Family planning / obstetric and perinatal screening and counselingmixedCovered

99401-99404, 99411-99412	Counseling and group counseling codes used across family planning and pregnancy-related counseling
Z71.3	Dietary counseling and surveillance
O00.XX-O99.XX, O9A.XX, Z34.00-Z34.03, Z34.80-Z34.83, Z34.90-Z34.93	Obstetric-related codes listed as required for pregnancy counseling services
80055, 80081	Obstetric panel (includes syphilis and hepatitis testing)
96127, 96161	Brief emotional/behavioral assessment screening instruments (depression/perinatal)
Z13.32	Encounter for screening for depression during and after pregnancy

Hypertensive disorders in pregnancy / preeclampsia screeningmixedCovered

99202-99205, 99212-99215	Office/outpatient evaluation and management codes listed for hypertensive disorders in pregnancy
Z01.30, Z01.31	Encounter for examination of blood-pressure

Substance abuse and mental health screening/counselingmixedCovered

96127	Brief emotional/behavioral assessment (depression screening)
Z13.31	Encounter for screening for depression
99408, 99409	Alcohol and substance abuse screening and brief intervention
Z13.39	Encounter for screening for other mental health and behavioral disorders
G0443	Brief face-to-face behavioral counseling for unhealthy alcohol use
Z71.41	Alcohol abuse counseling
F10.1-F10.19, F10.9-F10.99	Alcohol-related disorders codes range (required for unhealthy alcohol use counseling)

ContraceptionICD-10Covered

Z30.XXX

Encounter for contraceptive management

Colorectal cancer screening age — Age applicability

Applicable age>= 45 years for average risk

Applicable genderBoth

Procedure codes (examples)82270, G0328, G0120, G0121, G0105, G0104

Breast cancer screening age (mammography) — Age applicability

Applicable age>= 35 years for average risk

Applicable genderBoth

Screening ICD-10-CM codeZ12.31

Osteoporosis screening age — Age applicability

Applicable age50 years or older (female)

Applicable genderFemale

Procedure codes (DXA examples)76977, 77078, 77080, 77081, 77085, 77086

Abdominal aortic aneurysm screening age — Age applicability

Applicable age65 - 75 years (male)

Applicable genderMale

Procedure code76706 (abdominal aorta ultrasound)

Prediabetes and Type 2 Diabetes screening age — Age applicability

Applicable age35 - 70 years

Applicable genderBoth

Screening ICD-10-CM codeZ13.1

Provider Requirements and Billing Instructions

Prior Authorization

Prior Authorization Required

Lung cancer screening (low-dose CT) requires prior service authorization. Ensure authorization is obtained before scheduling or performing the screening to avoid claim denials.

Procedure codes: G0296 (counseling visit), 71271 (screening)
ICD-10-CM screening code: Z12.2

Note

Provider Action — submit appropriate codes

Include applicable procedure and screening ICD-10-CM codes on preventive service claims to ensure appropriate processing.

For lung cancer screening, submit G0296 and/or 71271 with Z12.2 as appropriate.
Omission of required codes may affect claim processing.

Documentation Required

Documentation and Coding

When submitting claims, document and include the applicable procedure codes and the screening ICD-10-CM codes. For lung cancer screening also document the service authorization reference number in the claim or supporting documentation.

Include procedure codes (e.g., G0296, 71271)
Include screening ICD-10-CM code Z12.2
If authorization is required, include authorization number on claim

Billing Rule

Claim Submission Requirement

Claims for preventive services must include the applicable procedure codes and screening ICD-10-CM codes; failure to do so may delay processing or result in denial.

Ensure Z12.2 is reported for lung cancer screening when applicable
Report G0296 and/or 71271 as the procedure codes on the claim

Prior Authorization

Service Authorization Required

Lung cancer screening requires prior service authorization; obtain authorization and document it on the claim to avoid denials.

Authorization covers low-dose CT screening (71271) and related counseling (G0296) when indicated

Background and Scope

This chart lists adult preventive screening services with the associated procedure and screening ICD-10-CM codes, the applicable age and gender for each service, and whether the service is separately billable. It also notes when additional requirements apply (for example, some services list required ICD-10-CM codes or prior authorization). Use the chart to determine when a preventive service is billable by confirming the procedure code, the corresponding screening ICD-10-CM diagnosis, and any age/gender or administrative requirements noted in the chart.

Key Definitions

Screening ICD-10-CM codes — Diagnosis codes used to indicate a preventive screening encounter

DefinitionDiagnosis codes used to indicate a preventive screening encounter (e.g., Z12.31 for mammography)

Common screening codes listedZ12.10 - Z12.13 (colorectal), Z12.31 (mammography), Z13.1 (diabetes), Z13.820 (osteoporosis)

Provider instructionInclude the applicable screening ICD-10-CM code on preventive service claims

Separately billable — Indicates whether the listed preventive service can be billed separately from other services

PurposeIndicates whether the listed preventive service can be billed separately from other services such as the Annual Wellness Exam

Examples - Separately billable = YesCervical Cancer Screening (Pap), Osteoporosis Screening (DXA), Abdominal Aortic Aneurysm screening

Examples - Separately billable = N/A or NoColorectal Cancer screening (N/A), Annual Wellness Exams (N/A), Hypertension Screening (No)