CurrentBlue Cross Blue Shield - MassachusettsPolicy MPC 071318_4C-1-BG (rev 2/25)

ACA Preventive Care Services Billing Guideline

Billing guideline describing preventive services that must be covered with no member cost share per the Affordable Care Act, listing CPT/HCPCS/lab/vaccine codes, diagnosis coding and modifier guidance, pharmacy preventive medications, and operation billing notes for Blue Cross Blue Shield of Massachusetts.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyACA Preventive Care Services Billing Guideline

Policy CodePolicy MPC 071318_4C-1-BG (rev 2/25)

Change TypeUpdates to PrEP, diagnosis coding, and preventive code guidance

Effective Date

Next Review Date

Key ActionBill preventive, screening, counseling, or wellness services with the preventive diagnosis in the primary position on the claim.

SourceLink

POLICY UPDATE CHANGES

Updated for PrEP coverage related to Apretude.

Updated to reflect new ICD-10 code Z29.81 for HIV PrEP.

Added link to Affordable Care Act Medications List.

Updated coverage for HIV PrEP when billed with diagnosis codes Z11.4 and Z20.6.

Women preventive services updated to add codes for breastfeeding supplies.

Clarified AAA screening also applies to men 60+ with history of AAA screening.

Prevention of HIV infection updated to list generic emtricitabine/tenofovir.

Lowered lung cancer screening age to 50 per USPSTF.

40+Preventive services/codes listed

ManyVaccine codes listed

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Newborn/pediatric preventive screens listed

PharmacyPharmacy preventive medications referenced

Policy overview & scope

This reimbursement rule implements the Affordable Care Act (ACA) preventive service coverage requirements: covered preventive services listed in this guideline are provided with no member cost share when performed by in-network providers. It aligns covered services with recommendations from the USPSTF, ACIP, Bright Futures, AAP, and HHS, and is current as of February 2025. Policy number: MPC 071318_4C-1-BG (rev 2/25). Payer: Blue Cross Blue Shield of Massachusetts. Scope summary: Billing guideline describing preventive services that must be covered with no member cost share per the Affordable Care Act, listing CPT/HCPCS/lab/vaccine codes, diagnosis coding and modifier guidance, pharmacy preventive medications, and operation billing notes for Blue Cross Blue Shield of Massachusetts.

Policy metadata

Policy NumberMPC 071318_4C-1-BG (rev 2/25)

PayerBlue Cross Blue Shield - Massachusetts

Policy TitleACA Preventive Care Services Billing Guideline

StatusCURRENT

Effective DateCurrent as of February 2025

Last Review2025-02

Next Review

Scope SummaryBilling guideline describing preventive services that must be covered with no member cost share per the Affordable Care Act, listing CPT/HCPCS/lab/vaccine codes, diagnosis coding and modifier guidance, pharmacy preventive medications, and operation billing notes for Blue Cross Blue Shield of Massachusetts.

Coverage criteria and rules

General preventive coverage and billing rules

Covered when ALL of the following are met:

ALL of the following

Service is an ACA-recommended preventive service based on USPSTF, ACIP, Bright Futures, AAP, or HHS recommendations
Check member eligibility and benefits; some plan designs or grandfathered plans may vary
Service is performed by an in-network provider (members may incur costs for out-of-network)
Primary diagnosis requirement: All diagnosis codes for preventive, screening, counseling, or wellness services should be billed in the primary position
Claims are subject to payment edits; benefits are based on primary diagnosis

Codes included in this guideline

Colorectal cancer screening and ancillary codesmixedCovered

44401
45303
45305
45307
45308
45309
45315
45320
45330
45331

1–10 of 44

1/5

Preventive screening and counseling common visit codesCPTCovered

99381	Preventive office visit
99382	Preventive office visit
99383	Preventive office visit
99384	Preventive office visit
99385	Preventive office visit
99386	Preventive office visit
99387	Preventive office visit
99391	Preventive office visit (child)
99392	Preventive office visit (child)
99393	Preventive office visit (child)

1–10 of 14

1/2

Immunization (vaccines & administration) codesmixedCovered

90375
90376
90378
90389
90396
90460
90461
90471
90472
90473

1–10 of 79

1/8

HIV screening and PrEP related codesmixedCovered

86689
86701
86702
86703
87390
87534
87535
87806
G0432
G0433

1–10 of 19

1/2

Abdominal aortic aneurysm screening codeCPTCovered

76706

Ultrasound for AAA screening - covered when billed with diagnosis code Z13.6

Falls prevention therapy codesCPTCovered

97161
97162
97163
97164

Colorectal screening stool/ancillary lab codesCPT|HCPCS|mixedCovered

82270
82272
82274

Cervical and HPV testing codesmixedCovered

0500T
87623
87624
87625
G0476
G0101	Cervical cancer screening (Pap test)
G0123
G0124
G0141
G0143

1–10 of 37

1/4

Breast screening mammography codesCPTCovered

77061
77063
77066
77067

Pediatric preventive, screening, and newborn codesmixedCovered

96110	Developmental screening for children under 3
96127	Brief emotional/behavioral assessment
G0451	Autism screening
82247	Bilirubin concentration (newborn)
82248	Bilirubin concentration
V5008	Hearing screening
92551
92552
92558
92585

1–10 of 17

1/2

Breastfeeding supplies and lactation codes & durable medical equipmentmixedCovered

99401	Breastfeeding counseling/education
99402
99403
99501
A4281	Breast pump supplies
A4282	Breast pump supplies
A4283	Breast pump supplies
A4284	Breast pump supplies
A4285	Breast pump supplies
A4286	Breast pump supplies

1–10 of 12

1/2

Contraception and sterilization surgical, methods, and counseling codesmixedCovered

00851
00952
58565
58600
58605
58611
58615
58670
58671
S6621

1–10 of 64

1/7

Laboratory screening codes (selected examples)mixedCovered

80061	Lipid panel / Cholesterol screening
83719
83721
80422	Diabetes/glucose tolerance
82947	Glucose; serum
82948
82950
82951
82952
80055	Hepatitis B surface antigen/related testing

1–10 of 11

1/2

Billing, documentation, and prior authorization actions

Billing Rule

Primary diagnosis requirement

Bill preventive, screening, counseling, or wellness services with the preventive diagnosis in the primary position on the claim.

Billing Rule

Modifier 33 placement

If reporting Modifier 33, place it in the first modifier field; modifier 33 is generally not used for benefit determinations except where indicated.

Billing Rule

Colorectal ancillary preventive payment

Ancillary colorectal screening services (00811, 00812, 81528, 82270, 82272, 82274, 88304, 88305, J2250, J3010) are paid as preventive when billed with Modifier 33 or PT and diagnosis code Z12.11. Note: codes G0104–G0106 and G0120–G0122 are exceptions to this preventive payment rule.

Key definitions

Definitions

Preventive serviceServices recommended by USPSTF, ACIP, Bright Futures, AAP, or HHS that are covered under the ACA with no additional member cost share when provided in-network.

Modifier 33Preventive services modifier which may be reported but is not used in benefit determination generally; place in first modifier field if reported.

Policy revisions & material changes

February 2025AddedLatest

Updated for PrEP coverage related to Apretude.

October 2023Revised

Updated to reflect the new ICD-10 code Z29.81 for HIV PrEP (effective for dates of service on and after October 1, 2023).

March 2023Added

FAQs and common billing questions

Operational guidance and quick FAQs for billing and clinical operations: Bill preventive, screening, counseling, or wellness services with the preventive/screening diagnosis code in the primary position on the claim because benefits are based on the primary diagnosis. If reporting Modifier 33, place it in the first modifier field; modifier 33 is not generally used for benefit determinations except where specifically indicated. Colorectal screening ancillary services are paid as preventive when billed with Modifier 33 or PT and diagnosis code Z12.11 (exceptions: G0104-G0106, G0120-G0122). HIV PrEP services (including Apretude J0379 and administration codes G0012 or 96372) are covered only when billed with ICD-10 diagnosis code Z29.81. Always verify member eligibility and benefits prior to performing services, as some plan designs or grandfathered plans may vary.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyACA Preventive Care Services Billing Guideline

Policy CodePolicy MPC 071318_4C-1-BG (rev 2/25)

Change TypeUpdates to PrEP, diagnosis coding, and preventive code guidance

Effective Date

Next Review Date

Key ActionBill preventive, screening, counseling, or wellness services with the preventive diagnosis in the primary position on the claim.

SourceLink

On This Page

Modifier 33 guidance: Modifier 33 may be reported but is not used for benefit determinations except where indicated; if reported place it in the first modifier field

Colorectal cancer screening preventive payment conditions

Preventive payment for colorectal screening ancillary services when billed with specified modifiers and diagnosis:

ALL of the following

Exceptions: Codes G0104-G0106 and G0120-G0122 are exceptions and are not included in the general preventive payment rule above

Falls prevention for older adults

Paid as preventive when ALL:

ALL of the following

Service codes: CPT 97161, 97162, 97163, 97164

Abdominal aortic aneurysm (AAA) screening

Covered when ALL of the following are met:

ALL of the following

Eligible populations (ONE of): Eligible populations include males ages 65-75 who have ever smoked, or men age 60 and older with a history of abdominal aortic aneurysm screening
Frequency: Covered once per lifetime for males ages 65-75 who have ever smokedOnce per lifetime

HIV PrEP preventive coverage

Covered when ALL of the following are met:

ALL of the following

Relevant codes (ONE or more): Includes laboratory and specimen codes (82565, 81025, 84702, 84703), preventive/visit codes (99384-99387, 99394-99397), counseling/screening codes (99401, 99402-99404), medication Apretude (J0379) and administration codes (G0012 or 96372)
Apretude added Feb 2025; Z29.81 effective Oct 1, 2023

Key thresholds

AAA screening frequencyCovered once per lifetime for males ages 65-75 who have ever smoked

Lung cancer screening age/frequencyLow-dose CT covered once annually for ages 50-80 when billed with diagnosis codes

Lipid/statin eligibilityStatin covered for adults 40-75 with no history of CVD and one or more CVD risk factors and a calculated 10-year CVD event risk >=10%

Affected codes: 00811, 00812, 81528, 82270, 82272, 82274, 88304, 88305, J2250, J3010
Paid as preventive when billed with Modifier 33 or PT and diagnosis Z12.11
Exceptions: G0104-G0106 and G0120-G0122

Billing Rule

Falls prevention therapy

Falls prevention therapy (CPT 97161–97164) must be submitted with Modifier 33 to be paid as a preventive service for older adults at increased risk for falls.

Affected CPT codes: 97161, 97162, 97163, 97164
Requirement: submit with Modifier 33 to be paid as preventive

Documentation Required

Check member eligibility and benefits

Always verify member eligibility and benefits prior to performing services; some plan designs or grandfathered plans may have differing preventive coverage.

Prior Authorization

Breast pump DME coverage

Coverage includes rental or purchase of one manual or electric breast pump per birth (excludes hospital-grade pumps for purchase). Listed DME and supply codes include E0602, E0603, A4281–A4286 and related supply codes; certain items require pharmacy benefits when dispensed (see policy for items marked as pharmacy benefit).

DME/supplies examples: E0602, E0603, A4281, A4282, A4283, A4284, A4285, A4286
One manual or electric pump per birth; hospital-grade pumps excluded from purchase coverage
Some items require pharmacy benefits (marked items in policy)

Billing Rule

HIV PrEP diagnosis requirement

Pre-exposure prophylaxis (PrEP) services — including Apretude (J0379) and related administration codes (G0012 or 96372) — are covered only when billed with ICD-10 diagnosis code Z29.81.

Relevant codes: Z29.81, J0379, G0012, 96372
PrEP services (including Apretude) covered only when billed with diagnosis Z29.81

Billing Rule

Preventive coding for osteoporosis screening

Osteoporosis screening (e.g., CPT 77080, 77081) is paid as preventive only when billed with diagnosis code Z13.820 or Z78.0. Use those diagnosis codes to receive preventive payment.

Example procedure codes: 77080, 77081
Required preventive diagnosis codes: Z13.820 or Z78.0

Added link to Affordable Care Act Medications List.

February 2023Revised

Updated coverage for HIV PrEP when billed with diagnosis codes Z11.4 and Z20.6.

February 2022Revised

Women preventive services updated to add codes for breastfeeding supplies.

July 2021Clarified

Clarified AAA screening also applies to men 60 and older with a history of abdominal aortic aneurysm screening.

May 2021Revised

Prevention of HIV infection updated to list the generic emtricitabine/tenofovir.

March 2021Revised

Lowered lung cancer screening age to 50 per USPSTF.