Blue Cross Blue Shield NM Preventive Coverage Update

General preventive coverage rules

Preventive services recommended by USPSTF (A/B), ACIP, HRSA, and Bright Futures are covered without member cost-share when obtained in-network for members under non-grandfathered plans; claims must include appropriate preventive diagnosis and procedure codes and meet listed criteria.

No member cost-share for USPSTF Grade A and B recommendations when services are provided in-network to members covered under non-grandfathered plans.

For a claim to process at the preventive level (no member cost-share), the claim must include a preventive diagnosis code, a preventive procedure code, and meet any applicable medical policy review criteria and guideline conditions (USPSTF/ACIP/HRSA/Bright Futures).

Services obtained out-of-network are not required to be covered without cost-share; members obtaining preventive services out-of-network are subject to copay, deductible, and coinsurance per their plan's out-of-network benefit level.

Grandfathered plans are exempt from the federal no cost-share requirement but may elect to provide preventive services at no member cost-share; verify plan-specific benefits for coverage details.

Selected USPSTF recommendation-specific coverage rules

Selected USPSTF recommendations and associated procedure codes/criteria (partial list).

Abdominal Aortic Aneurysm (AAA) screening: one-time abdominal ultrasound for men aged 65–75 who have ever smoked; procedure code 76706 reimbursable as preventive when submitted with an appropriate preventive diagnosis code.

BRCA-related risk assessment and genetic testing: perform brief familial risk assessment; positive screens should receive counseling and, if indicated, genetic testing. Specified BRCA testing procedure codes are reimbursable as preventive when submitted with the listed primary diagnosis codes; services are subject to Medical Policy and prior authorization may be required.

Breast cancer screening (mammography): biennial screening mammography for women aged 50–74; screening mammography codes (77061–77067) are payable at the preventive level when billed with an appropriate Diagnosis List 1 code.

Colorectal cancer screening: recommended for adults 50–75 (A) and 45–49 (B); multiple stool, endoscopic and lab procedure codes listed. Certain colorectal screening services may be subject to medical policy criteria and prior authorization. Preventive colonoscopy with same-encounter polypectomy and related services process at the preventive level when billed with the appropriate screening diagnosis.

Gestational diabetes screening: screen asymptomatic pregnant persons at or after 24 weeks (preferably 24–28 weeks); listed lab CPT codes apply and services are payable with a pregnancy diagnosis as indicated.

Preventive coverage criteria (excerpt)

Preventive coverage criteria (excerpt): services recommended by USPSTF A/B are covered at the preventive level when billed with appropriate codes and, where specified, appropriate diagnosis linkage (pregnancy diagnosis or Diagnosis List 1).

HIV/PrEP and related services: Pre‑exposure prophylaxis (PrEP): clinicians should offer/prescribe PrEP to persons at increased risk (USPSTF A). Baseline and monitoring services related to PrEP medication are reimbursable at the preventive level; pharmacy benefit details are managed via the member's drug list and the phone number on the member's BCBS card.

Pregnancy-linked infectious disease screening: Hepatitis B screening in pregnant women: USPSTF A — screen at first prenatal visit; listed lab codes (e.g., 80055, 86704, 36415) are payable with a pregnancy diagnosis or a Diagnosis List 1 code.

HIV screening: USPSTF A — recommended for adolescents and adults (and for all pregnant persons); listed procedure and lab codes apply and are payable when billed with a pregnancy diagnosis or a Diagnosis List 1 code as indicated.

Hypertension screening in adults: USPSTF A — ambulatory and home blood pressure monitoring and related procedure codes (e.g., 93784, 99473) are reimbursable at the preventive level when billed with the specified diagnosis codes.

Screening-specific payment criteria

Screening-specific payment criteria and payment linkage notes.

Anxiety screening: procedure code 96127 is reimbursable at the preventive level only when billed with specified diagnosis codes (e.g., Z00.129, Z13.31, Z13.32, Z13.39, Z13.41, Z13.42).

Screening mammography: HRSA recommends average‑risk women initiate screening between age 40 and 50 and continue at least biennially through at least age 74; mammography procedure codes are payable at the preventive level when billed with an appropriate Diagnosis List 1 code.

Breastfeeding equipment and provider reimbursement rules

Breastfeeding equipment coverage and provider reimbursement rules.

Breastfeeding equipment: manual pumps (E0602), electric pumps (E0603), and hospital‑grade pumps (E0604) and certain supplies (A4281–A4286) are covered at the preventive level under non‑grandfathered plans when obtained in‑network per policy rules.

Electric breast pumps (E0603) must be rented or purchased from an in‑network provider or contracted DME supplier; members are allowed one electric breast pump per benefit period. Hospital‑grade pumps (E0604) are limited to rental only, covered up to $1,000 or 12 months when rented in‑network, and members are allowed one hospital pump per benefit period.

Non‑physician providers (e.g., Certified Lactation Counselors, IBCLCs) may be eligible for limited reimbursement for specified lactation support codes (for example S9443 and the listed counseling codes) per the provider‑type and code limitations described in the policy.

Diabetes screening rules

Diabetes screening after pregnancy and gestational diabetes guidance.

Postpartum diabetes screening after gestational diabetes (GDM): women with a history of GDM who are not currently pregnant and not previously diagnosed with type 2 diabetes should have initial testing within the first year postpartum (as early as 4–6 weeks); rescreen at least every 3 years for a minimum of 10 years. Initial testing CPT codes include 82947, 82948, 82950, 82951, 83036.

Gestational diabetes screening in pregnancy: screen pregnant women after 24 weeks (preferably 24–28 weeks) using a 50 g oral glucose challenge test followed by a 3‑hour 100 g OGTT if abnormal; these services are payable with a pregnancy diagnosis as indicated.

Immunization coding and payment notes

ACIP-recommended vaccines and associated procedure codes and payment notes.

ACIP‑recommended vaccines listed include COVID‑19, DTaP, Hepatitis A, Hepatitis B, Hib, HPV, influenza, MMR, MMRV, meningococcal, pneumococcal, polio, RSV, rotavirus, Tdap/Td, varicella, zoster, and immunization administration codes (90460 series).

Specific payment notes: for example, Hepatitis B vaccination is payable at the preventive level for newborns under 90 days of age when obtained inpatient from an in‑network provider; other vaccines may require diagnosis linkage per the policy (e.g., HPV vaccines noted payable with Diagnosis List 1 when indicated).

Vaccine coverage

List of covered vaccines (ACIP) and referenced procedure codes.

Vaccines enumerated in the policy with CPT/HCPCS procedure codes include (examples): COVID‑19 (0121A, 0141A, etc.), DTaP (90696, 90698, 90700, 90702, 90723), Hepatitis A (90632–90636), Hepatitis B (90739, 90740, 90743, etc.), Hib (90647–90648), HPV (90649–90651), influenza (90630 series; Q2034–Q2039), MMR (90707), MMRV (90710), meningococcal (90619, 90620, 90621, 90644, 90733–90734), pneumococcal (90670, 90677, 90732), polio (90713), RSV (90380–90381), rotavirus (90680–90681), Tdap/Td (90714–90715), varicella (90716), zoster (90736, 90750), and immunization administration codes (90460–90474).

Immunization administration codes (90460 series and others) are listed for use with vaccine administration when billed per guidance.

Bright Futures screenings

Bright Futures preventive screening and counseling services; many are payable at the preventive level only when billed with Diagnosis List 1 codes and have age‑specific applicability.

Bright Futures recommends numerous age‑based screening and counseling services (examples include alcohol/drug use assessments for adolescents (99408/99409), anemia screening (85014/85018), developmental/depression screening (96110), hearing screening (92558 series), HIV screening, lead screening, vision screening (99173), oral health risk assessments, and preventive medicine visits). Many of these procedure codes are payable at the preventive level only when billed with a Diagnosis List 1 code as specified.

Age restrictions: Bright Futures recommendations reference specific age ranges for applicability (e.g., newborn through 21 years for many screenings); providers must bill consistent with the indicated age ranges and diagnosis linkage for preventive‑level processing.

Breastfeeding equipment & limitations

Breastfeeding equipment coverage details and listed limitations/exclusions.

Covered breastfeeding equipment and supplies: manual breast pump (E0602), electric breast pump (E0603), hospital‑grade breast pump (E0604; rental only), and specified replacement supplies (A4281–A4286) are covered at the preventive level when obtained in‑network per policy rules. Members are allowed one electric or one hospital pump per benefit period; hospital‑grade pumps are covered up to $1,000 or 12 months when rented in‑network.

Retail/out‑of‑network rules: electric pumps must be rented/purchased in‑network; retail providers (e.g., general retailers, online vendors) are considered out‑of‑network and out‑of‑network preventive coverage follows the plan's out‑of‑network benefit level and may include cost sharing and sales tax considerations.

Limitations and exclusions: the policy excludes breastfeeding items not listed in the breastfeeding equipment section (examples: batteries, ointments/creams, certain storage supplies and cleaning accessories, travel cases, infant scales, nursing bras/covers), and immunizations not published in CDC MMWR or not FDA‑licensed for use in the U.S.; pharmacy coverage and age limits may vary by plan.

Preventive vs Diagnostic guidance

Guidance to distinguish preventive services from diagnostic services to support correct coding and benefit determination.

Definition — Preventive services: screenings intended to prevent illness or identify issues before symptoms are evident, and counseling interventions defined by a specific preventive recommendation. Use preventive diagnosis/procedure codes and applicable guideline linkage to obtain preventive‑level reimbursement.

Definition — Diagnostic services: services for diagnosis of existing symptoms or abnormalities, treatment or management of specific health conditions, or tests ordered to evaluate signs/symptoms; these follow the diagnostic benefit path and may be subject to cost sharing.

Examples to guide billing: preventive scenario — a 60‑year‑old woman obtains a biennial screening mammogram; diagnostic scenario — the same woman obtains a mammogram after noticing a breast lump (diagnostic). Similarly, preventive colonoscopy for average‑risk screening differs from diagnostic colonoscopy done for symptoms; apply the appropriate diagnosis code to reflect the clinical intent when billing.

Billing, Authorization, and Documentation Notes for Providers

Prior Authorization

Prior Authorization Required for LDCT Lung Cancer Screening

Procedure code 71271 (LDCT) is subject to Medical Policy criteria and requires prior authorization when used for lung cancer screening. Submit supporting documentation showing the member meets USPSTF criteria (age, smoking history, current smoker or quit within 15 years) and include appropriate diagnosis code. Reimbursable when criteria met.

Procedure code 71271 requires preauthorization (Eff. 01/01/2021).
Submit diagnosis supporting eligibility (e.g., 20+ pack-year, current smoker or quit ≤15 years).
Procedure code 60296 and 71271 listed for LDCT screening.

Billing Rule

Anxiety Screening — Diagnosis Required for Preventive Reimbursement

Procedure code 96127 (brief emotional/behavioral assessment) and preventive visit codes are reimbursable at the preventive level only when billed with the specified anxiety screening diagnosis codes. Ensure the correct diagnosis is submitted to avoid denial.

Code 96127 reimbursable at preventive level only with diagnosis Z00.129, Z13.31, Z13.32, Z13.39, Z13.41, or Z13.42.
Preventive visit CPTs (e.g., 99384–99397, G0444) may be used for anxiety screening per WPSI guidance.

Billing Rule

Contraceptive Procedures — Billing and Diagnosis Requirements

FDA-approved contraceptive procedures and devices are covered at the preventive level when billed with the appropriate diagnosis codes. Insertion/removal procedures have specific CPTs that should be billed with listed diagnosis codes to qualify as preventive.

Contraceptive services and devices (IUDs, implants, injectables, oral contraception, patches, rings, diaphragms, etc.) are covered per HRSA/WPSI guidance.
Insertion/removal CPTs (e.g., 58661, 58700) reimbursable when billed with one of the specified diagnosis codes (see policy).
When billing for contraceptive implant insertion or removal, include one of the listed diagnosis codes to receive preventive-level reimbursement.

Billing Rule

HIV Screening — Billing and Diagnosis Guidance

HIV screening tests and counseling are reimbursable at the preventive level when billed with an eligible diagnosis from Diagnosis List 1. Screen all adolescent and adult women at least once and rescreen based on risk; document pregnancy screening and rescreening during pregnancy as applicable.

Covered HIV screening CPT/HCPCS include 36415, 86689, 86701–86703, 87389–87391, 87806, G0432 and rapid-test codes as listed.
Preventive reimbursement requires billing with a Diagnosis List 1 code when indicated.
For pregnant patients, document initiation of prenatal care and risk-based rescreening; rapid testing recommended in labor if status undocumented.

Note

Well‑Woman Visits — Reimbursement Notes

Well-woman preventive visits (annual) are covered to deliver recommended preventive services across the lifespan. Use appropriate preventive CPTs and bill labs related to normal pregnancy with a pregnancy diagnosis to obtain preventive-level reimbursement.

Use preventive CPTs (e.g., 99384–99397, G0101) for well-woman visits.
Labs administered as part of a normal pregnancy are reimbursable at the preventive level when billed with a pregnancy diagnosis.
Coordinate services across visits as clinically appropriate to deliver recommended preventive services.

Documentation Required

Breastfeeding Equipment & Supplies — Coverage Rules and Billing Notes

Non-grandfathered plans cover breast pumps and supplies at the preventive level but have provider/source and supply-specific rules. Choose billing source and codes carefully to ensure correct network-level reimbursement and avoid member balance billing.

Manual pumps (E0602) payable at preventive level when obtained In-Network, Out-of-Network, or retail; sales tax excluded for retail purchases.
Electric pumps (E0603) must be rented or purchased from an In‑Network provider or contracted DME supplier; one electric pump per benefit period. Upgraded models may result in member balance billing for the difference.
Hospital‑grade pumps (E0604) covered only when rented In‑Network or from In‑Network DME supplier; coverage up to $1,000 or 12 months, whichever comes first; unit must be returned at end of coverage.
Breast pump supplies (A4281–A4286) reimbursable at preventive level; some group coverage limitations may apply.
Breast pumps obtained Out‑of‑Network reimbursable at Out‑of‑Network preventive benefit level (potential cost sharing).

Key Terms and Lists

ACIP

AcronymACIP = Advisory Committee on Immunization Practices

RoleMakes immunization recommendations referenced by the policy

Coverage linkageACIP-recommended vaccines listed with CPT/HCPCS procedure codes for preventive reimbursement

USPSTF

AcronymUSPSTF = United States Preventive Services Task Force

Recommendation gradesPolicy covers USPSTF A and B recommendations without member cost-share for non-grandfathered plans in-network

Use in policyMultiple USPSTF screening and counseling recommendations and associated CPT codes are enumerated

HRSA

AcronymHRSA = Health Resources and Services Administration

Focus areasWomen’s Preventive Services Initiative recommendations referenced (e.g., breastfeeding, gestational diabetes, postpartum diabetes screening)

Billing linkageHRSA-recommended services referenced with CPT/HCPCS codes and diagnosis billing notes

Preventive-level payable condition

DefinitionPayable at the preventive level when billed with a pregnancy diagnosis or a Diagnosis List 1 code

Common contextsUsed for prenatal labs (e.g., hepatitis B), maternal depression screening and many prenatal/perinatal services

Claim requirementClaims must include the specified diagnosis code to process as preventive-level reimbursement

Diagnosis-linked preventive reimbursement

DefinitionProcedure codes are reimbursable at the preventive level only when billed with the specified diagnosis codes (e.g., Diagnosis List 1 or pregnancy DX)

ExamplesAmbulatory blood pressure monitoring (93784) and home BP training (99473) require listed diagnosis codes to be preventive

ImplicationProviders must append the correct preventive diagnosis to avoid diagnostic-level cost sharing

Breastfeeding equipment and supplies (HRSA)

Included itemsDouble electric breast pumps (E0603), manual (E0602), hospital-grade pumps (E0604) and related supplies (A4281–A4286)

Coverage limitsOne electric or hospital pump allowed per benefit period; hospital-grade pumps limited to rental and covered up to $1,000 or 12 months when rented in‑network

Provider & network noteElectric pumps must be rented/purchased in‑network; retail providers are considered out‑of‑network

Gestational Diabetes Screening (HRSA)

Timing for gestational diabetes screeningScreen pregnant women after 24 weeks of gestation (preferably 24–28 weeks)

Preferred testing approach50 g oral glucose challenge test, followed by 3‑hour 100 g OGTT if initial test abnormal

Billing notePayable with a pregnancy diagnosis as indicated

Preventive services

Core definitionPreventive services: screenings or counseling to prevent illness or detect problems before symptoms appear

ExamplesUSPSTF/ACIP/HRSA/Bright Futures screenings and counseling enumerated in policy

Coverage implicationPreventive services meeting criteria are covered without member cost‑share for non‑grandfathered plans when obtained in‑network

Diagnostic services

Core definitionDiagnostic services: evaluation or treatment of existing symptoms, management of known conditions, or tests to monitor disease

ExamplesDiagnostic mammogram for a new breast lump; lab tests for management of diabetes

Billing implicationDiagnostic-level services are not subject to preventive no cost‑share rules and may incur member cost‑share per plan benefits

Diagnosis List 1

PurposeDiagnosis List 1 is the set of diagnosis codes required for many services to be payable at the preventive level

UsageMany Bright Futures, prenatal, and screening procedure codes are payable at preventive level only when billed with a Diagnosis List 1 code

LocationDiagnosis List 1 codes are enumerated in the policy (see Diagnosis List 1 section) for provider reference

Policy Update Log

2023-09-25coding_and_recommendation_updatesLatest

Coding and USPSTF recommendation updates incorporated into the preventive services policy.

2023-06-01coding_and_recommendation_updates

Coding and USPSTF recommendation updates incorporated into the policy.

2023-05-24coding_and_recommendation_updates

Coding and USPSTF recommendation updates incorporated into the policy.

2023-03-16coding_and_recommendation_updates_and_hyperlink_updates

Coding and USPSTF recommendation updates and hyperlink updates made to the policy.

2023-03-16coding_updates

Coding and recommendation updates applied to the policy (entry also notes hyperlink updates).

2023-02-20coding_updates

Coding updates made to the preventive services policy.

2022-09-09coding_and_recommendation_updates

Coding and USPSTF recommendation updates incorporated into the policy.

2022-06-01coding_and_recommendation_updates_and_diagnosis_list_update

Coding and USPSTF recommendation updates; Diagnosis List 1 updates included in the policy.

2022-03-23coding_and_recommendation_updates

Coding and USPSTF recommendation updates incorporated into the policy.

2021-12-16coding_and_uspstf_updates

Coding and USPSTF updates made to the preventive services policy.

2021-09-22coding_and_recommendation_updates_and_drug_info_updates

Coding and USPSTF recommendation updates along with drug information updates applied to the policy.

2021-01-12coding_updates

Coding updates applied to the policy.

2020-12-21coding_and_recommendation_updates_and_drug_info_updates

Coding and USPSTF recommendation updates plus drug information updates and disclaimers added to the policy.

2020-09-09coding_and_recommendation_updates

Coding and USPSTF recommendation updates incorporated into the policy.

2020-06-08coding_and_recommendation_updates_and_disclaimer_updates

Coding and USPSTF recommendation updates and disclaimer, coding, and link updates made to the policy.

2020-04-20recommendation_updates

Recommendation updates to USPSTF items reflected in the policy.

2019-12-30coding_and_disclaimer_updates

Coding updates and disclaimer language added to the policy.

2019-10-14hpv_vaccine_update

HPV vaccine coding updates implemented in the policy.

2018-12-27coding_and_uspstf_updates

Coding and USPSTF updates applied to the policy.

2018-07-12coding_and_uspstf_updates

Coding and USPSTF updates applied to the policy.

2018-04-30coding_and_uspstf_updates

Coding and USPSTF updates applied to the policy.

2017-12-06coding_and_uspstf_updates

Coding and USPSTF updates applied to the policy.

2017-07-14code_removals

Removed CPT codes 99174 and 99177 from the policy coding list.

2017-06-23policy_creation

New preventive services policy created, replacing medical policy ADM1001.030.

44388	Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
45378	Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
45380	Colonoscopy, flexible; with biopsy, single or multiple
45381	Colonoscopy, flexible; with directed submucosal injection(s), any substance
45384	Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps
G0106	Colorectal cancer screening; flexible sigmoidoscopy
G0121	Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk
G0122	Colorectal cancer screening; colonoscopy on individual meeting criteria for high risk

OpenPayer

Preventive Services Policy

Preventive Coverage Criteria

Procedure, Vaccine, and Screening Codes

Billing, Authorization, and Documentation Notes for Providers

Key Terms and Lists

Policy Update Log