Blue Cross Blue Shield WI preventive coding Coverage

Coverage Criteria — Preventive Services

Covered Preventive Services

Covered when in accordance with referenced authoritative recommendations and in-network provider:

Coverage prerequisites: Service is a USPSTF A or B recommendation, an ACIP routine vaccine, HRSA Bright Futures or WPSI recommended service where applicable; vaccines follow ACIP/FDA labeling; member received service from an in-network provider to qualify for cost-share waiver.

References: USPSTF/ACIP/HRSA/WPSI; in-network required for cost-share waiver

Wellness Visits (age-based)

Covered when delivered as preventive/wellness visits per age ranges

Wellness visit age-based coverage: Wellness visits following AAP Bright Futures are covered from birth through age 21 with specified CPT codes for infant, early childhood, late childhood, adolescent and adult categories; a yearly wellness visit should occur after age 21.

Codes: 99381-99398 series, 99459, S0610-S0613, G0402, G0438-G0439; wellness visits do not require a diagnosis code for the preventive benefit to apply but appropriate diagnosis codes should be submitted

Assessments and Counseling

Assessments and counseling covered when meeting guideline populations and coding rules

Behavioral & preventive screening/counseling: Screenings and counseling recommended by USPSTF, WPSI, and Bright Futures (e.g., behavioral assessments, anxiety/depression screening, hypertension screening, diet/physical activity counseling, IPV screening, STI counseling) are covered; these services are normally part of the wellness visit; when provided outside a preventive visit a listed diagnosis code is required for the preventive benefit to apply.

G0445 limited to twice a year; counseling and screening codes include 99401-99404, 99411-99412, 96127, 96160-96161, G0444, G0445, 93784-93790, G0446/G0447 etc.

Immunizations (ACIP)

Immunizations recommended per ACIP are covered with provided vaccine and administration codes

ACIP-recommended vaccines: Vaccines recommended by ACIP across age groups (including COVID-19, DTaP/Tdap, HepA, HepB, HPV, influenza, pneumococcal, RSV, rotavirus, measles/mumps/mumps) are covered with listed administration and product codes; the listed diagnosis code Z23 is requested but not required; if billed with an evaluative/preventive service append an appropriate modifier (such as -25 or -59) to indicate separate services.

Refer to CDC immunization schedule and plan pharmacy benefit for vaccine options; administration codes include 90460-90474, 90480, M0201, etc.

Breast Cancer Screening (USPSTF and WPSI)

Covered when ALL of the following are met:

Breast cancer screening age and interval: Women aged 40 to 74 years; initiate screening between 40 and 50 and continue through at least 74; screening at least biennially and up to annually depending on age and patient choice per USPSTF/WPSI guidance.Age 40-74

Procedure codes: mammography 77065/77066/77067; tomosynthesis and MRI codes listed; 77063 and 77067 do not require a diagnosis code for preventive benefit but other procedures require listed diagnosis codes

BRCA-Related Cancer: Risk Assessment, Genetic Counseling, and Genetic Testing (USPSTF)

Covered when ALL of the following are met:

BRCA risk assessment population: Women age 18 years and older with a personal or family history of breast, ovarian, tubal, or peritoneal cancer or ancestry associated with BRCA1/2 mutations should receive brief familial risk assessment; positive results warrant genetic counseling and, if indicated, genetic testing.Age >= 18

Procedure codes include office visit codes (99202-99205, 99211-99215, 99385-99397), genetic counseling (96041, S0265), BRCA lab codes (81162-81167, 81212, etc.); normally requires prior authorization and a listed diagnosis code for the preventive benefit

Breast Cancer: Medications for Risk Reduction (USPSTF)

Covered when ALL of the following are met:

Risk-reducing medications: Asymptomatic women age 35 years and older who are at increased risk for breast cancer and at low risk for adverse medication effects may be offered risk-reducing medications (e.g., tamoxifen, raloxifene, aromatase inhibitors) in accordance with USPSTF guidance.Age >= 35

Office visit and counseling codes listed; medication coverage is managed under the plan's pharmacy benefit; prescriptions and counseling are normally part of the office visit; if provided outside an office visit a listed diagnosis code is required for preventive benefit

Colorectal Cancer Screening (USPSTF)

Covered when ALL of the following are met:

Colorectal screening ages and intervals: Asymptomatic adults aged 45 to 75 years (45-49 Grade B; 50-75 Grade A) are covered for colorectal cancer screening with modality-specific intervals per USPSTF: high-sensitivity gFOBT/FIT yearly; sDNA-FIT every 1–3 years; CT colonography every 5 years; flexible sigmoidoscopy every 5–10 years; colonoscopy every 10 years.Age 45-75

Procedure codes listed (fecal tests 82270/82274/G0328; FIT-DNA 0464U/81528; colonoscopy and CT codes listed); some colorectal screenings may require prior authorization and many codes require a listed diagnosis code for preventive benefit

Sexual Health Screenings (USPSTF)

Covered when ALL of the following are met:

Chlamydia/Gonorrhea screening: Sexually active women aged 24 years or younger and older women at increased risk should be screened for chlamydia and gonorrhea; screening requires a listed diagnosis code for the preventive benefit to apply.Sexually active women <=24 or at increased risk

Procedure codes include 86631/86632, 87110, 87270, 87320, 87490-87492, 87801, 87590-87592 and blood draw codes 36415/36416

Syphilis screening: Asymptomatic, nonpregnant adolescents and adults at increased risk for syphilis should be screened; screening requires a listed diagnosis code for the preventive benefit to apply.At increased risk

Procedure codes include 86592/86593/86780 and blood draw codes 36415/36416

Chlamydia and Gonorrhea Screening (USPSTF Grade B)

Covered screening when population definitions met and diagnosis codes support preventive benefit:

Chlamydia/Gonorrhea Screening: Sexually active women aged 24 years or younger, or older women at increased risk; diagnosis codes for screening and blood draw include Z11.3, Z11.8, Z29.81; procedure and blood draw codes listed.age <=24 or at increased risk

Requires a listed diagnosis code for the preventive benefit to apply

Syphilis Screening (USPSTF Grade A)

Covered screening when population definitions met and diagnosis codes support preventive benefit:

Syphilis Screening: Asymptomatic, nonpregnant adolescents and adults at increased risk for syphilis infection; diagnosis codes include Z11.2, Z11.3, Z11.8, Z29.81; procedure and blood draw codes listed.increased risk

Requires a listed diagnosis code for the preventive benefit to apply

HIV Infection Screening (USPSTF Grade A)

Covered screening when population definitions met and diagnosis codes support preventive benefit:

HIV Screening: Adolescents and adults aged 15 to 65 years, and younger or older persons at increased risk, should be screened for HIV; diagnosis codes include Z11.3, Z11.4, Z11.59, Z29.81; procedure and blood draw codes listed.age 15-65 or increased risk

Requires a listed diagnosis code for the preventive benefit to apply

Preexposure Prophylaxis (PrEP) for HIV Prevention (USPSTF Grade A)

Covered prevention when population definitions met; additional administrative requirements:

PrEP for HIV Prevention: Persons (including adolescents) not infected with HIV who are at high risk should be offered PrEP; prior authorization may apply and prescriptions are required for PrEP injections/medications; pharmacy preventive benefit may supply options.high risk for HIV acquisition

Procedure and monitoring codes listed (injection admin 96372, medication J-codes/G0012, kidney testing 82565/82575, pregnancy test 81025, Q0521 pharmacy supply fee); requires a listed diagnosis code

Cervical Cancer Screening (HPV testing) (USPSTF Grade A)

Covered cervical cancer screening per USPSTF/WPSI when criteria met:

Cervical Cancer Screening: Asymptomatic women with a cervix: ages 21–29 years screened with cervical cytology every 3 years; ages 30–65 years screened every 3 years with cytology alone or every 5 years with hrHPV testing alone or with cotesting; requires listed diagnosis codes for the preventive benefit.age 21–65 with cervix

Collection and lab codes (Q0091, 88141–88175, 87623–87626, G0476) listed; diagnosis codes include Z01.411, Z01.419, Z11.51, Z12.4, Z12.72

Contraceptive Services and Counseling (USPSTF and WPSI Grade A)

Covered contraceptive services when provided according to guidance:

Contraceptive Services and Counseling: Applies to adolescent and adult women with a cervix; includes screening, education, counseling, provision, insertion/removal, follow-up and sterilization procedures; wellness exam codes include counseling and are not separately reimbursable when performed as part of a wellness exam; counseling/services outside a preventive visit require a listed diagnosis code for the preventive benefit.female members with cervix (per WPSI)

Extensive procedure and supply codes listed (sterilization 58565/58600-series, implantable 11981-11983, IUD codes 58300/58301, J-codes for supplies, 96372 for injectable administration, etc.); refer to plan pharmacy benefit for contraceptives available under pharmacy preventive benefit

Gestational Diabetes Screening

Covered preventive screenings for pregnant women when criteria below apply

Gestational diabetes screening criteria: Screen asymptomatic pregnant women for gestational diabetes after 24 weeks' gestation (preferably between 24 and 28 weeks); WPSI recommends earlier screening for women with risk factors at the first prenatal visit; requires a listed diagnosis code and a pregnancy diagnosis listing code for the preventive benefit.timing after 24 weeks

Procedure codes include glucose tests 82947–82952, A1c 83036/83037; blood draw codes 36415/36416; diagnosis Z13.1; postpartum screening guidance provided separately

Prenatal Infectious Disease Screening (HBV, HIV, Syphilis)

Covered prenatal infectious disease screenings

Infectious disease screenings: Pregnant women should be screened at the first prenatal visit for hepatitis B, HIV, and syphilis with listed procedure and blood draw codes; requires a listed pregnancy diagnosis code for the preventive benefit to apply.first prenatal visit

Procedure codes: hepatitis panels 80055/80081, HBsAg 87340/87341, HIV panels 80081/86689 etc.; diagnosis codes include Z11.59, Z20.5 and pregnancy diagnosis listing

Rh(D) Incompatibility Screening

Rh(D) incompatibility screening

Rh(D) screening: Blood typing and antibody testing for all pregnant women at their first pregnancy-related visit; repeat antibody testing at 24–28 weeks for unsensitized Rh(D)-negative women unless father known Rh-negative; requires a pregnancy diagnosis listing code for the preventive benefit.first visit and 24-28 weeks

Procedure codes include 80055, 80081, 86850, 86901; blood draw 36415/36416

Breastfeeding Services and Supplies

Breastfeeding support coverage

Breastfeeding services: Comprehensive lactation support services, counseling, lactation classes, breast pumps, replacement parts, and storage supplies are covered for pregnant and postpartum women; counseling is normally part of a wellness visit; other DME and supplies require appropriate diagnosis codes for preventive benefit.pregnancy and postpartum

Procedure and supply codes listed include counseling 99401-99404, lactation classes S9443, breast pumps E0602/E0603, replacement parts A4281–A4288; replacement supplies provided at no cost as needed; one personal-use electric breast pump per pregnancy

Newborn Care Screening and Prophylaxis

Newborn screenings and prophylaxis

Newborn screening and prophylaxis: Bilirubin screening, newborn metabolic screening panel, hematocrit/hemoglobin, congenital hypothyroidism, phenylketonuria screening, and ocular prophylaxis for gonococcal ophthalmia neonatorum are covered for newborns (age 0–90 days); these services are typically included as part of delivery and require listed diagnosis codes if performed separately.age 0-90 days

Procedure codes include 82247, 88720, S3620, 83020, 84437, 84030; blood draw codes 36415/36416; ocular prophylaxis is included as part of delivery

Preventive Medications (Folic Acid, Aspirin)

Preventive medication recommendations

Folic acid and aspirin: Recommend folic acid (0.4–0.8 mg) for women planning or capable of pregnancy and low-dose aspirin (81 mg/day) after 12 weeks for persons at high risk of preeclampsia; these preventive medications are part of the plan's pharmacy benefit.after 12 weeks for aspirin

Refer to plan pharmacy benefit for coverage details

Newborn screenings

Newborn preventive services covered when criteria below apply

Ocular prophylaxis: Prophylactic ocular topical medication for all newborns per USPSTF is included as part of delivery.newborn

Typically included as part of delivery; no separate procedure codes listed in this chunk

Phenylketonuria screening

Newborn metabolic screening

Phenylketonuria screening: PKU screening for newborns age 0–90 days with procedure codes S3620 and 84030 and blood draw codes 36415/36416; diagnosis codes Z13.0, Z13.21, Z13.228, Z13.29; typically included as part of delivery and requires a listed diagnosis code if performed separately.age 0-90 days

Follow state-specific newborn screening requirements

Child & Adolescent preventive screenings and interventions

Child and adolescent screenings covered when ALL listed age and coding conditions are met

Anemia screening at 12 months per Bright Futures with procedure codes 85014/85018 and blood draw codes 36415/36416; requires a listed diagnosis code for the preventive benefit.age 12 months

Diagnosis code Z13.0

Hearing screening per Bright Futures at newborn, infancy, and periodic ages through 21 years with procedure codes 92551/92552/92558/92567/92587/92588/92650/92651/V5008; requires a listed diagnosis code for the preventive benefit.age 0-21 years

Diagnosis codes include Z00.121, Z00.129, Z00.110, Z00.111, Z01.10, Z01.110, Z01.118

Developmental and autism screening: Formal developmental screening at recommended early visits (e.g., 9, 18, 24, 30 months) and autism screening at 18 and 24 months using codes 96110, 96127, G0451; requires listed diagnosis codes.age 9 months through 2 years

Hepatitis B screening (adolescents at risk)

Adolescent immunization and infection screening

Hepatitis B screening: Adolescents at increased risk should be screened for hepatitis B using codes 86704–86707, 87340/87341, G0499 with blood draw codes 36415/36416; diagnosis codes include Z11.59 and Z20.5; requires a listed diagnosis code for the preventive benefit.age 12-18 years for adolescents at increased risk

Refer to immunization and Bright Futures guidance

Tuberculosis testing (Bright Futures)

TB testing

Tuberculosis testing for HIV-infected children: Annual TB testing for children infected with HIV using screening code 86580 and follow-up visit code 99211; diagnosis code Z11.1; note that there is no separate administration code for the PPD test and one should not be reported.HIV-infected children

Requires a listed diagnosis code for the preventive benefit

Abdominal aortic aneurysm (AAA) screening

Abdominal aortic aneurysm screening criteria

AAA screening: One-time abdominal ultrasound for men aged 65–75 who have ever smoked (procedure code 76706); requires a listed diagnosis code for the preventive benefit to apply.age 65-75 and ever smoked

Diagnosis codes include smoking-related and screening codes

Cervical cancer screening (Pap testing)

Cervical cancer screening

Pap testing age 21-29: Women ages 21–29: cervical cytology every 3 years with collection code Q0091 and lab codes (88141–88175, G0123–G0148, P3000/P3001); wellness visit codes 99385–99396; requires a listed diagnosis code for collection and testing services though wellness visits do not require a diagnosis for the preventive benefit.age 21-29 years

Diagnosis codes include Z00.00, Z00.01, Z01.411, Z01.419, Z12.31, Z12.4, Z12.72

Pap/HPV testing age 30-65: Women ages 30–65: screening every 3 years with cytology alone or every 5 years with hrHPV testing alone or cotesting per USPSTF/WPSI; collection and testing services require a listed diagnosis code for preventive benefit.age 30-65 years

HPV testing codes 87623–87626, G0476 and related lab/collection codes listed

Lung cancer screening (LDCT)

Lung cancer screening

Annual LDCT screening: Annual low-dose CT (LDCT) screening for adults aged 50–80 with a >=20 pack-year smoking history who currently smoke or quit within the past 15 years; discontinue screening after 15 years since quitting or if limited life expectancy; procedure codes include 71271 and G0296; normally requires prior authorization and a listed diagnosis code for the preventive benefit.age 50-80 and >=20 pack-year and current or recent smoker

Diagnosis codes include Z71.6, F17.x, Z87.891

Osteoporosis screening (DXA)

Osteoporosis screening

DXA screening: Screen women aged 65 and older and postmenopausal women younger than 65 at increased risk with bone measurement testing (DXA); procedure codes include 77080, 77081, 77085, G0130; requires a listed diagnosis code for the preventive benefit and excludes women with prior low-trauma fractures or secondary osteoporosis conditions.women >=65 or younger with increased risk

Diagnosis codes include Z13.820, Z78.0, Z79.890, Z82.62; exclusions apply for low-trauma fractures/secondary causes

Prediabetes and Type 2 diabetes screening

Diabetes screening: Screen asymptomatic nonpregnant adults aged 35–70 who are overweight or obese for abnormal blood glucose as part of cardiovascular risk assessment; screening interval approximately once every 3 years; procedure codes include 82947 and 83036; requires listed diagnosis codes for the preventive benefit and referral to intensive behavioral interventions when abnormal.age 35-70 and overweight/obese

Diagnosis codes Z13.1, R73.03, R73.09; refer to weight-loss/behavioral interventions and plan pharmacy benefit for treatment

Osteoporosis screening