CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Preventive Services for Medicare Advantage Plans

Governs coverage, cost-sharing, and coding guidance for Medicare Advantage preventive services for providers submitting claims to Blue Cross Blue Shield - Rhode Island; applies to Medicare Advantage members and contracted providers.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPreventive Services for Medicare Advantage Plans

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun 1, 2024

Next Review DateN/A

Key ActionDo not submit prior authorization requests for preventive services; file claims per coding guidelines to ensure no member cost share.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

NonePrior authorization

No member cost shareCost-sharing stance

Facility cost share may applyFacility billing rule

G0438/G0439Key codes cited

Preventive Services Coverage and Billing Rules

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Preventive services coverage and billing rules

Coverage and billing rules for preventive services and related coding requirements:

Preventive services coverage: Preventive services, as defined in the coding section of this policy, are covered at no cost share for the member; claims must be filed according to the guidelines in the coding section to ensure correct claims processing.

Annual visit coding interaction

If Annual Wellness Visit (G0438 or G0439) and an Annual Physical Exam (99385-99387 or 99395-99397) are performed on the same date of service by a PCP, PA, or NP, the member's medical record must document that the requirements for use of both codes are met.
The Annual Physical Exam (99385-99387, 99395-99397) is not considered a preventive service under this policy; refer to the member's Evidence of Coverage for applicable benefits.

Depression screening with AWV

Depression screening (G0444) is not reimbursed when filed with the initial Annual Wellness Visit (G0438) because G0438 includes a depression screening by standardized instrument, assessment of functional ability and level of safety.
G0444 will be reimbursed when performed and documented with the subsequent Annual Wellness Visit (G0439), because G0439 does not include the depression screen or the assessment of functional ability and level of safety.

Screening follow-up colonoscopy timing: A screening follow-up colonoscopy is considered a preventive service when performed within six months of the initial screening colonoscopy per USPSTF guidance; if a follow-up claim is submitted with member cost share, contact the Call Center or Provider Relations to have the claim identified and processed with no member cost share according to the preventive policy.

Contact Call Center 401-274-4848 or ProviderRelations@bcbsri.org if claim initially applies member cost share.

Facility charge billing rule: When preventive and non-preventive services are performed at the same time in an institutional setting, facility cost sharing will be applied only when the higher-priced procedure is a non-preventive service; if the higher-priced procedure is preventive, facility cost sharing will not be applied (e.g., colonoscopy and endoscopy performed together — no facility cost sharing if colonoscopy is higher priced).

Claims filing requirement: To ensure correct claims processing of preventive services, claims must be filed as noted on the attached coding grid with any diagnosis listed on the grid in the primary position on the claim.

Codes, Timing, and Coding Guidance

Notable codes and guidanceCPT | HCPCS | mixed

G0438	Annual Wellness Visit, initial
G0439	Annual Wellness Visit, subsequent
G0444	Depression screening
99385-99387	Initial comprehensive preventive medicine evaluation
99395-99397	Periodic comprehensive preventive medicine evaluation
00811	Anesthesia for lower intestinal endoscopic procedures (added 1/1/2018 reference)

Timing for preventive follow-up colonoscopy

Preventive follow-up colonoscopy timingA screening follow-up colonoscopy is considered a preventive service when performed within six months of the initial screening colonoscopy.

Action if claim posts with member cost shareIf a follow-up claim posts with member cost share, contact Call Center 401-274-4848 or Provider Relations at ProviderRelations@bcbsri.org to have the claim reviewed and processed with no member cost share.

Claim filing guidanceClaims for preventive services must be filed according to the coding section/grid and include the applicable diagnosis in the primary position to ensure correct processing.

Definitions and Scope

Services covered at no cost share (Medicare / ACA)

No member cost share for USPSTF A/B servicesMany preventive services recommended with an A or B grade by the USPSTF are covered with no deductible, coinsurance, or copayment per the Affordable Care Act and Medicare guidance.

Clinical laboratory testsCertain clinical laboratory tests are also covered without member cost share under statute provisions where deductible/coinsurance do not apply.

Preventive services coverage applies to Medicare Advantage membersMedicare Advantage plans: preventive services defined in the coding section are covered at no cost share for the member, subject to coding/grid filing requirements.

Exceptions where cost share may applySome services on the preventive grid may still have copays, coinsurances, or deductibles applied per CMS; follow coding grid guidance to determine applicability.

Annual Physical Exam — policy stance and coding

Annual Physical Exam codesCPT codes 99385-99387 and 99395-99397 describe the Annual Physical Exam (comprehensive preventive medicine evaluations).

Coding when performed with AWVIf an Annual Physical Exam and an Annual Wellness Visit (G0438 or G0439) are performed on the same date by the same PCP/PA/NP, documentation must support use of both codes and meet requirements for each code.

OpenPayer

Preventive Services for Medicare Advantage Plans

Preventive Services Coverage and Billing Rules

Codes, Timing, and Coding Guidance

Provider Requirements and Actions

Definitions and Scope