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    OpenPayer is built and maintained by Trek Health.

    v1.0.28
    OpenPayerPolicy UpdatesPreventive Services & ScreeningBlue Cross Blue Shield WI preventive coding Covera…
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    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    CurrentBlue Cross Blue Shield - WisconsinPolicy MULTI-BCBS-CM-003812-25-GRP1128

    ACA preventive care coding guidelines

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    Defines coverage, coding, and billing guidance for preventive services required under the Affordable Care Act (ACA) for Anthem/BCBS plans including Blue Cross Blue Shield of Wisconsin; applies to in-network providers and members for preventive benefit determinations.

    Policy Summary
    PayerBlue Cross Blue Shield - Wisconsin
    PolicyACA preventive care coding guidelines
    Policy CodePolicy MULTI-BCBS-CM-003812-25-GRP1128
    Change TypeNo material change
    Effective Date
    Last ReviewFeb 1, 2026
    Next Review Date
    Key ActionInclude the appropriate listed preventive diagnosis code on the claim for the preventive benefit to apply.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    USPSTF A/Bpreventive recommendations covered
    ACIPvaccination schedule referenced
    Onepersonal electric breast pump per pregnancy (in-network)
    No cost-sharepreventive services in-network (cost-share)
    Twice/yr
    G0445 limit
    ~100+procedure & diagnosis codes

    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

    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

    Covered when ALL of the following are met

    Osteoporosis screening criteria: Women 65 years and older; postmenopausal women younger than 65 at increased risk as determined by a formal clinical risk assessment tool; no history of low-trauma fractures and no conditions causing secondary osteoporosis.age >=65 or high-risk per assessment

    Procedure codes: 77080, 77081, 77085, G0130; requires a listed diagnosis code for the preventive benefit

    Prediabetes and Type 2 Diabetes screening

    Covered when ALL of the following are met

    Diabetes screening criteria: Asymptomatic nonpregnant adults aged 35 to 70 who are overweight or obese; screening interval once every 3 years; clinicians should offer or refer patients with abnormal blood glucose to intensive behavioral counseling interventions.age 35-70 and overweight/obese

    Procedure codes include 82947 and 83036; requires a listed diagnosis code for the preventive benefit

    Unhealthy alcohol use screening and Depression screening

    Covered when ALL of the following are met

    Alcohol screening: Adults age 18 years and older (including pregnant women) should be screened for unhealthy alcohol use and persons engaged in risky drinking offered brief behavioral counseling interventions.age >=18

    Procedure codes include 99408, 99409, G0442, G0443; requires a listed diagnosis code for the preventive benefit

    Depression screening: Screen adults (including pregnant/postpartum persons and older adults) for depression using recommended screening tools; requires a listed diagnosis code for the preventive benefit.age >=18

    Procedure codes include 96127, G0444

    Tobacco cessation and Unhealthy drug use screening

    Covered when ALL of the following are met

    Tobacco cessation: Clinicians should ask all adults about tobacco use, advise cessation, and provide behavioral interventions and FDA‑approved pharmacotherapy as appropriate for adults age 18 and older.age >=18

    Procedure codes include 99406 and 99407; pharmacy cessation options available under plan pharmacy benefit; requires a listed diagnosis code for preventive benefit if provided outside preventive visit

    Unhealthy drug use screening: Screen adults aged 18 years and older for unhealthy drug use when services for diagnosis, treatment, and referral can be offered; requires a listed diagnosis code for the preventive benefit.age >=18

    Procedure codes include 99408, 99409, G0396, G0397, G0442, G0443, G2011

    Weight loss/Obesity behavioral interventions

    Covered when ALL of the following are met

    Obesity behavioral intervention: Adults with BMI >=30 should be offered or referred to intensive, multicomponent behavioral interventions; counseling is normally part of a wellness visit and requires a listed diagnosis code if provided outside a preventive visit.BMI >=30

    Procedure codes include medical nutrition therapy 97802–97804, G0270/G0271, S9470; preventive counseling 99401–99404; behavioral counseling 0403T, G0446, G0447

    Hepatitis B and C screening

    Covered when ALL of the following are met

    Hepatitis B screening: Adults age 18 and older at increased risk for HBV infection should be screened using listed procedure and blood draw codes; requires a listed diagnosis code for the preventive benefit.age >=18 and increased risk

    Procedure codes include 86704–86707, 87340/87341, G0499; blood draw 36415/36416

    Hepatitis C screening: Adults aged 18 to 79 years should be screened at least once for HCV with listed procedure and blood draw codes; requires a listed diagnosis code for the preventive benefit.age 18-79

    Procedure codes include 86803/86804, G0472; blood draw 36415/36416; diagnosis codes Z11.59 for one-time screening

    Latent tuberculosis infection (LTBI) screening

    Covered when ALL of the following are met

    LTBI screening: Asymptomatic adults at increased risk for latent tuberculosis infection (LTBI) should be screened using appropriate tests and follow-up; requires a listed diagnosis code for the preventive benefit.age >=18 and increased risk

    Procedure codes include 86480/86481/86580 and blood draw codes 36415/36416; follow-up visit code 99211; diagnosis codes Z11.7, R76.11/R76.12

    Falls prevention in older adults

    Covered when ALL of the following are met

    Falls prevention: Community-dwelling adults age 65 years or older who are at increased risk for falls should be offered exercise interventions to prevent falls; requires a listed diagnosis code for the preventive benefit.age >=65

    Procedure codes include PT/therapy codes 97110, 97112, 97116, 97530, 97750 and relevant G/S codes; diagnosis code Z91.81

    Statin use for primary prevention of cardiovascular disease

    Covered when ALL of the following are met

    Statin primary prevention: Adults aged 40 to 75 with one or more cardiovascular risk factors and an estimated 10-year ASCVD risk >=10% should be prescribed a statin for primary prevention; requires listed diagnosis codes and appropriate risk assessment.age 40-75 and ASCVD 10-year risk >=10%

    Screening/lab codes include lipid panel 80061, 82465, 83718–83722, 84478 and ASCVD risk assessment codes G0537/G0538; refer to plan pharmacy benefit for statin coverage

    The preventive benefit does not apply to services that are handled under the member's pharmacy benefit (for example, prescription drugs) or to services that are diagnostic rather than preventive. Vaccines are only considered preventive when used in accordance with FDA labeling; vaccines or vaccine administration provided outside FDA labeling or for non-medical reasons (travel, employment, school, license maintenance, adoption/marriage, court, sports/camp) are excluded. Additionally, services that are investigational, experimental, unproven, not medically necessary, or provided off‑label are not covered under the preventive benefit. Such services may, however, be covered under other portions of the member’s medical or pharmacy benefits—providers and members should consult the applicable plan documents.

    The USPSTF/WPSI behavioral counseling code G0445 (STI behavioral counseling) is subject to a frequency limit and is limited to twice per year. When G0445 is furnished outside of a wellness visit, ensure a listed preventive diagnosis code is included for the preventive benefit to apply.

    Member cost shares (deductible, copay, coinsurance) will apply when services fall outside preventive coverage rules, including services provided to an inappropriate age group, services delivered at intervals outside USPSTF recommendations, or services performed for diagnostic, surveillance, therapeutic, or treatment purposes rather than as screening/prevention.

    Contraceptive counseling that is provided as part of a covered wellness/annual preventive exam is included in the wellness visit payment and is not separately reimbursable. If contraceptive counseling or services are furnished outside a preventive visit, submit the appropriate listed diagnosis code(s) for the preventive benefit to apply.

    The postpartum diabetes screening (screening for diabetes mellitus after pregnancy) is a preventive benefit for postpartum women; however, the preventive benefit will not apply if a diabetes diagnosis code is present in any position on the claim. Providers should verify diagnosis coding before billing to determine whether the preventive benefit is applicable.

    For tuberculosis skin testing (PPD), there is no separate administration code to report. Do not submit an additional administration code for the PPD test; billing should follow the procedure and diagnosis codes listed for TB testing and any associated follow‑up visit codes.

    Routine osteoporosis screening per USPSTF excludes women who have a history of low‑trauma fractures or who have conditions that cause secondary osteoporosis. The preventive screening recommendation and coverage apply to women aged ≥65 and to younger postmenopausal women only when they are at increased risk and have no history of low‑trauma fractures or secondary causes.

    Services that are investigational, experimental, unproven, not medically necessary, or provided off‑label are not considered preventive services under this policy and therefore are not covered as preventive care. Providers should determine whether such services may be covered through other medical or pharmacy benefit provisions.

    This policy references USPSTF, ACIP, HRSA Bright Futures, and WPSI guidance to define covered preventive services and the coding, timing, and population criteria that determine when the preventive benefit applies. For complete topic‑specific criteria, age thresholds, procedure and diagnosis code lists, and any prior authorization or pharmacy‑benefit details, refer to the full preventive services sections in the document for each screening, immunization, counseling or intervention.

    Coding — Procedure and Diagnosis Codes

    Wellness Visit and Annual Wellness Procedure CodesCPT | HCPCSCovered
    99381Wellness Visit - Infant
    99391Wellness Visit - Infant
    99461Wellness Visit - Infant
    99382Wellness Visit - Early Childhood Age 1-4 years
    99392Wellness Visit - Early Childhood Age 1-4 years
    99383Wellness Visit - Late Childhood Age 5-11 years
    99393Wellness Visit - Late Childhood Age 5-11 years
    99384Wellness Visit - Adolescent Age 12-17 years
    99394Wellness Visit - Adolescent Age 12-17 years
    99459Wellness Visit - Adolescent / Other listed
    1–10 of 22
    1/3
    Diagnosis Codes referenced for wellness/annual examsICD-10
    Z00.110Health examination for newborn under 8 days
    Z00.111Health examination for newborn 8-28 days
    Z00.121Encounter for routine child health examination with abnormal findings
    Z00.129Encounter for routine child health examination without abnormal findings
    Z00.00Encounter for general adult medical examination without abnormal findings
    Z00.01Encounter for general adult medical examination with abnormal findings
    Z01.411Encounter for gynecological examination (general) with abnormal findings
    Z01.419Encounter for gynecological examination (general) without abnormal findings
    Z12.31Encounter for screening mammogram for malignant neoplasm of breast
    Z12.4Encounter for screening for malignant neoplasm of cervix
    1–10 of 11
    1/2
    Covered CPT Codes - Preventive/Wellness VisitsCPTCovered
    99381Wellness Visit - Infant
    99391Wellness Visit - Infant
    99461Wellness Visit - Infant
    99382Wellness Visit - Early Childhood Age 1-4
    99392Wellness Visit - Early Childhood Age 1-4
    99383Wellness Visit - Late Childhood Age 5-11
    99393Wellness Visit - Late Childhood Age 5-11
    99384Wellness Visit - Adolescent Age 12-17
    99394Wellness Visit - Adolescent Age 12-17
    99459Wellness Visit / care coordination (listed with adolescent/adult)
    1–10 of 16
    1/2
    Covered CPT/HCPCS Codes - Counseling and ScreeningmixedCovered
    99401Preventive Medicine Individual Counseling / Behavioral counseling
    99402Preventive Medicine Individual Counseling / Behavioral counseling
    99403Preventive Medicine Individual Counseling / Behavioral counseling
    99404Preventive Medicine Individual Counseling / Behavioral counseling
    99411Group counseling
    99412Group counseling
    96127Brief emotional/behavior assessment screening
    96160Health behavior assessment/intervention (individual)
    96161Health behavior assessment/intervention (group/family)
    G0445Behavioral counseling for STI prevention
    1–10 of 12
    1/2
    Covered CPT Codes - Blood Pressure ScreeningCPTCovered
    93784Blood pressure screening CPT listed
    93786Blood pressure screening CPT listed
    93788Blood pressure screening CPT listed
    93790Blood pressure screening CPT listed
    Covered CPT/HCPCS Codes - Immunizations & relatedmixedCovered
    90460Vaccine administration (multiple codes listed)
    90461Vaccine administration
    90471Immunization administration (child)
    90472Immunization administration (adult)
    90473Oral/other administration
    90474Oral/other administration
    90480Immunization administration
    M0201Vaccine administration modifier/identifier listed
    G0008Influenza vaccine administration
    G0402Annual wellness visit - not a preventive visit code listed
    1–10 of 13
    1/2
    Covered Immunization Product Codes (vaccines)CPTCovered
    91318COVID-19 immunization (6 months to 4 years)
    91321COVID-19 immunization (6 months to 11 years)
    91319COVID-19 immunization (5 to 11 years)
    91304COVID-19 immunization (12 years and older)
    90696DTaP/Hib/IPV combination or similar (listed among DTP/pertussis)
    90697Diphtheria-tetanus-acellular pertussis (DTaP)
    90698Diphtheria-tetanus-acellular pertussis
    90700DTP/DTaP
    90702Diphtheria and tetanus toxoids
    90714Tdap
    1–10 of 31
    1/4
    Diagnosis Codes referenced for Preventive ServicesICD-10
    Z00.110Health exam for newborn
    Z00.111Health exam for newborn
    Z00.121Routine child health examination
    Z00.129Routine child health examination unspecified
    Z00.00Encounter for general adult medical examination without abnormal findings
    Z00.01Encounter for general adult medical examination with abnormal findings
    Z23Encounter for immunization
    Immunization administration and vaccine codes (selected)CPT | HCPCS
    90460Administration
    90461Administration
    90471Administration
    90472Administration
    90619Immunization
    90620Immunization
    90621Immunization
    90623Immunization
    90624Immunization
    90644Immunization
    1–10 of 12
    1/2
    Additional vaccine codesCPT | HCPCS
    90707Immunization
    90710Immunization
    90670Pneumococcal immunization
    90671Pneumococcal immunization
    90677Pneumococcal immunization
    90732Pneumococcal immunization
    90473Administration
    90474Administration
    90680Rotavirus immunization
    90681Rotavirus immunization
    1–10 of 13
    1/2
    More vaccine codesCPT | HCPCS
    90696Immunization
    90697Immunization
    90698Immunization
    90700Immunization
    90702Immunization
    90714Td/Tdap immunization
    90715Td/Tdap immunization
    90723Immunization
    90644Hib immunization
    90647Hib immunization
    1–10 of 11
    1/2
    Zoster vaccine codesCPT | HCPCS
    90736Zoster immunization
    90750Zoster immunization
    Breast cancer screening codesCPT | HCPCS | RevenueCovered
    77065Mammography
    77066Mammography
    77067Mammography (diagnostic/screening)
    C8903Breast MRI
    77063Tomosynthesis
    G0279Tomosynthesis
    76641Breast ultrasound
    19081Pathology-related breast surgery
    BRCA risk assessment and testing codesCPT | HCPCSCovered
    99202Office visit
    99203Office visit
    96041Genetic counseling
    S0265Genetic counseling
    81162BRCA lab screening
    81163BRCA lab screening
    81164BRCA lab screening
    81212BRCA testing
    Colorectal cancer screening codesCPT | HCPCSCovered
    82270Fecal occult blood testing
    82274Fecal occult blood testing
    G0328FIT
    0464UFIT-DNA
    81528FIT-DNA
    G0105Colonoscopy screening
    G0121Colonoscopy screening
    74263CT colonography
    Chlamydia and Gonorrhea screening codesCPTCovered
    86631Chlamydia screening
    86632Chlamydia screening
    87110Microbiology
    87270Chlamydia/Gonorrhea test
    87320Gonorrhea test
    87490Chlamydia NAAT
    87491Chlamydia NAAT
    87801Chlamydia/Gonorrhea testing
    87590Gonorrhea/cervical NAAT
    Chlamydia and Gonorrhea Screening codesCPT | mixedCovered
    86631Screening (chlamydia/gonorrhea) - as listed
    86632Screening (chlamydia/gonorrhea) - as listed
    87110Screening (chlamydia/gonorrhea) - as listed
    87270Screening (chlamydia/gonorrhea) - as listed
    87320Screening (chlamydia/gonorrhea) - as listed
    87490Screening (chlamydia/gonorrhea) - as listed
    87491Screening (chlamydia/gonorrhea) - as listed
    87492Screening (chlamydia/gonorrhea) - as listed
    87801Screening (chlamydia/gonorrhea) - as listed
    87810Screening (chlamydia/gonorrhea) - as listed
    1–10 of 16
    1/2
    Syphilis Screening codesCPT | mixedCovered
    86592Syphilis screening
    86593Syphilis screening
    86780Syphilis screening
    36415Blood Draw
    36416Blood Draw
    HIV Infection Screening codesCPT | HCPCS | mixedCovered
    80081HIV screening (listed)
    86689HIV screening
    86701HIV screening
    86702HIV screening
    86703HIV screening
    87389HIV screening
    87390HIV screening
    87391HIV screening
    87534HIV screening
    87535HIV screening
    1–10 of 22
    1/3
    PrEP and related services codesCPT | HCPCS | HCPCS J-codes | mixedCovered
    96372Injection administration (PrEP injections)
    G0012Injection/Oral medication (PrEP) - listed
    J0738Injection/Oral Med (PrEP) - listed
    J0739Injection/Oral Med (PrEP) - listed
    J0750Injection/Oral Med (PrEP) - listed
    J0751Injection/Oral Med (PrEP) - listed
    J0752Injection/Oral Med (PrEP) - listed
    J0799Injection/Oral Med (PrEP) - listed
    82565Kidney testing (PrEP monitoring)
    82575Kidney testing (PrEP monitoring)
    1–10 of 23
    1/3
    Cervical cancer screening (PAP and HPV) codesCPT | HCPCS | mixedCovered
    Q0091Collection for PAP
    88141PAP test
    88142PAP test
    88143PAP test
    88147PAP test
    88148PAP test
    88150PAP test
    88152PAP test
    88153PAP test
    88155PAP test
    1–10 of 32
    1/4
    Contraceptives and related services codesCPT | HCPCS | J-codes | mixedCovered
    58565Sterilization - hysteroscopy
    58600Sterilization - minilaparotomy or laparotomy
    58605Sterilization - listed
    58611Sterilization - listed
    58615Sterilization - listed
    58661Laparoscopy sterilization
    58670Laparoscopy sterilization
    58671Laparoscopy sterilization
    58340Tubal ligation follow-up
    74740Tubal ligation follow-up imaging (listed)
    1–10 of 56
    1/6
    Diagnosis codes for screenings and contraceptive servicesICD-10 | mixed
    Z11.3Screening for infections (listed across services)
    Z11.8Other screening for infectious/parasitic diseases
    Z29.81Encounter for antiretroviral drug therapy (PrEP/HIV screening context)
    Z11.2Screening for syphilis
    Z11.4Screening for HIV
    Z11.59Other screening for STIs
    Z01.411Encounter for gynecological exam (with cervical cytology)
    Z01.419Encounter for gynecological exam (without cytology)
    Z11.51Encounter for screening for human papillomavirus
    Z12.4Encounter for screening for malignant neoplasm of cervix
    1–10 of 11
    1/2
    Pregnancy diagnosis code listing (extensive O09/O30 series)ICD-10
    O09.01Pregnancy diagnosis code listing (document lists many O09.x and O30.x mappings)
    O09.213Pregnancy diagnosis code listing
    O30.001Pregnancy diagnosis code mapping examples
    Z33.1Pregnancy-related code referenced in listing
    Z34.00Pregnancy-related code referenced in listing
    Gestational Diabetes Screening CPT/Blood drawCPTCovered
    82947Glucose testing
    82948Glucose testing
    82950Glucose testing
    82951Glucose testing
    82952Glucose testing
    83036Hemoglobin A1c
    83037Hemoglobin A1c
    36415Collection of venous blood by venipuncture
    36416Collection of capillary blood
    Gestational Diabetes Screening DiagnosisICD-10
    Z13.1Encounter for screening for diabetes mellitus
    Postpartum Diabetes Screening DiagnosisICD-10
    Z13.1Encounter for screening for diabetes mellitus
    Z86.32Personal history of gestational diabetes
    Depression Screening/Counseling CodesCPTCovered
    96127Brief emotional/behavioral assessment
    96160Administration of patient-focused health risk assessment
    G0444Annual depression screening
    Healthy Weight and Behavioral Counseling Procedure CodesCPTCovered
    97802Medical nutrition therapy; initial assessment and intervention
    97803Medical nutrition therapy; re-assessment and intervention
    97804Medical nutrition therapy, group
    G0270Physician nutritionist visit
    G0271Dietitian visit
    S9470Nutritional counseling
    99401Preventive medicine counseling
    99402Preventive medicine counseling
    99403Preventive medicine counseling
    99404Preventive medicine counseling
    1–10 of 12
    1/2
    Hepatitis B and related prenatal screening codesCPTCovered
    80055Hepatitis panel
    80081HIV test panel
    87340Hepatitis B surface antigen
    87341Hepatitis B surface antigen
    87467Chlamydia NAAT
    Rh(D) Incompatibility Screening CodesmixedCovered
    86850Blood typing
    86901Antibody screen
    Z01.83Encounter for blood-typing and antibody testing
    HIV Screening Procedure CodesCPTCovered
    80081HIV test panel
    86689HIV test
    G0432HIV screening
    G0433HIV screening with counseling
    S3645HIV test (specific HCPCS listed)
    36415Blood Draw
    Infectious Disease Screening Diagnosis CodesICD-10
    Z11.3Encounter for screening for infections with a predominantly sexual mode of transmission
    Z11.4Encounter for screening for viral diseases
    Breastfeeding Services and Supplies CodesmixedCovered
    99401Preventive medicine counseling
    99402Preventive medicine counseling
    99403Preventive medicine counseling
    99404Preventive medicine counseling
    99411Preventive medicine counseling, group
    99412Preventive medicine counseling, group
    98960Education and training for self-management
    98961Education and training for self-management
    98962Education and training for self-management
    S9443Breastfeeding classes
    1–10 of 20
    1/2
    Newborn Screening Procedure CodesCPTCovered
    82247Bilirubin; quantitative
    88720Transcutaneous bilirubinometry
    S3620Newborn metabolic screening panel
    83020Hematocrit
    83021Hemoglobin; glycosylated
    84437Thyroid stimulating hormone (TSH)
    84443Thyroxine; total (T4)
    84030Phenylalanine
    Newborn Screening Diagnosis Codesmixed
    S3620Newborn metabolic screening panel
    Z13.0Encounter for screening for mental disorders? (used in document for newborn screening group)
    Z13.21Encounter for screening for hemoglobinopathies
    Z13.228Encounter for screening for other disorders
    Z13.29Encounter for other screening for conditions
    Phenylketonuria screening codesmixed
    S3620Phenylketonuria screening
    84030Phenylketonuria screening laboratory
    36415Blood draw
    36416Blood draw, other
    Z13.0Encounter for screening for certain diseases and disorders
    Z13.21Screening for metabolic disorders
    Z13.228Other screening for genetic and chromosomal anomalies
    Z13.29Other screening for metabolic disorders
    Child screening — anemia, hearing, developmental codesmixed
    85014Automated hematocrit
    85018Hematocrit (Hct)
    92551Screening test, pure tone, air only
    92552Pure tone audiometry
    92558Tympanometry
    92567Tympanometry with acoustic reflex testing
    92587Evoked otoacoustic emissions test
    92588Evoked otoacoustic emissions test, limited
    92650Tympanometry and reflex measures
    92651Hearing aid check
    1–10 of 13
    1/2
    Substance use and counseling codesmixed
    99406Smoking and tobacco use cessation counseling intermediate
    99407Smoking and tobacco use cessation counseling intensive
    99408Alcohol and/or substance abuse structured screening and brief intervention services
    99409Alcohol and/or substance abuse structured screening and brief intervention services, greater than 30 minutes
    G0442Annual alcohol misuse screening
    G0396Alcohol and/or substance abuse structured screening
    G0397Follow-up for G0396
    G2011Remote evaluation of recorded video and/or images
    F17.290Other nicotine dependence
    Z71.41Counseling on substance use
    Behavioral, developmental, and depression screeningmixed
    96127Brief emotional/behavioral assessment
    96110Developmental screening
    G0451Developmental testing
    Z13.31Encounter for screening for depression
    Z13.32Encounter for screening for suicide risk
    High BMI/obesity interventions and codesmixed
    97802Medical nutrition therapy; initial assessment and intervention
    97803MNT; re-assessment and intervention
    97804MNT for group
    G0446Intensive behavioral therapy for obesity
    99401Preventive medicine counseling
    Z68.30BMI 30.0-30.9, adult
    E66.01Obesity due to excess calories

    Provider Actions — Billing, Authorization, Documentation

    Note

    Reasonable Medical Management

    The ACA allows reasonable medical management to determine coverage limits when guidance doesn't specify frequency, method, treatment, or setting. Techniques that may be used include precertification, concurrent review, claim review, or similar practices to determine coverage limitations for preventive services.

    Prior Authorization

    Prior Authorization May Be Required

    Some preventive services or related procedures normally require prior authorization. Examples include lung cancer screening with low-dose CT (LDCT) and certain genetic testing and counseling related to BRCA. Check plan-specific prior authorization rules before scheduling or performing these services.

    • Lung cancer screening (LDCT) — prior authorization normally required for 71271, G0296.
    • BRCA-related genetic counseling and testing — normally requires prior authorization; genetic counseling may be required prior to testing.

    Background and Scope

    Preventive services encompass screenings, vaccinations, counseling, and interventions intended to prevent disease or detect health issues at an early, asymptomatic stage. Anthem follows authoritative sources (for example, USPSTF grades A/B, ACIP vaccine recommendations, HRSA Bright Futures, and WPSI guidance) when defining covered preventive services; coverage and the cost‑share waiver generally require the service to be delivered by an in‑network provider and to meet the policy’s age, interval, and coding criteria.

    Definitions

    Preventive service — services encompassing screenings, vaccinations, counseling, and interventions intended to prevent or detect health issues at an early stage
    DefinitionServices encompassing screenings, vaccinations, counseling, and interventions intended to prevent or detect health issues at an early stage; provided to asymptomatic persons and not diagnostic procedures.
    ComponentsIncludes screenings, immunizations, counseling, and preventive interventions
    PurposeIntended to detect health issues early and prevent disease progression
    Wellness visit — preventive office visit across age-based categories with specific CPT codes
    DefinitionWellness visit: preventive office visit across age-based categories (infant through adult) following AAP Bright Futures with specific CPT codes (e.g., 99381–99398 series)
    Age coverage
    Policy Summary
    PayerBlue Cross Blue Shield - Wisconsin
    PolicyACA preventive care coding guidelines
    Policy CodePolicy MULTI-BCBS-CM-003812-25-GRP1128
    Change TypeNo material change
    Effective Date
    Last ReviewFeb 1, 2026
    Next Review Date
    Key ActionInclude the appropriate listed preventive diagnosis code on the claim for the preventive benefit to apply.
    SourceLink
    On This Page
    Coverage Criteria — Preventive ServicesCoding — Procedure and Diagnosis CodesProvider Actions — Billing, Authorization, DocumentationBackground and ScopeDefinitions

    Diagnosis codes Z13.40–Z13.42, Z13.41

    Fluoride varnish: Application of fluoride varnish to primary teeth from eruption until age 5 with procedure code 99188; requires listed diagnosis codes for preventive benefit; refer to pharmacy benefit for fluoride supplements.age <=5 years

    Diagnosis codes include Z00.121, Z00.129, Z29.3, Z91.841–Z91.849

    Vision screening ages 3-5: Vision screening at least once between ages 3 and 5 to detect amblyopia/risk factors with codes 99173/99174/99177; requires a listed diagnosis code for the preventive benefit.age 3-5 years

    Diagnosis codes Z01.020, Z01.021, Z00.121, Z00.129

    High BMI interventions: Children/adolescents >=6 years with BMI >=95th percentile should be provided or referred to comprehensive intensive behavioral interventions; procedure codes include 97802–97804, G0270/G0271, 99401–99404, 0403T, G0446/G0447; requires listed diagnosis codes.>=95th percentile

    Diagnosis codes include Z71.3, Z72.4, BMI/obesity codes

    Fluoride varnish — pediatric dental preventionmixed
    99188Application of topical fluoride varnish
    Z29.3Observation for prophylactic measures
    Z91.841Personal history of local (dental) preventive measures
    Vision screening codes (age 3-5)mixed
    99173Visual acuity screening
    99174Instrument-based vision screening
    99177Alternative vision screening
    Z01.020Encounter for examination of eyes and vision, child
    Hepatitis B screening codesmixed
    86704Hepatitis B surface antigen
    86705Hepatitis B core antibody
    87340Hepatitis B surface antigen test
    G0499Hepatitis B screening (lab)
    Z11.59Encounter for screening for other viral diseases
    Tuberculosis testing codesmixed
    86580Tuberculosis test (PPD)
    99211Office visit, established patient, minimal
    Z11.1Encounter for screening for respiratory tuberculosis
    AAA screening codeCPT
    76706Abdominal ultrasound, complete (for AAA screening)
    Cervical cancer screening and wellness visit codesmixed
    99385Initial comprehensive preventive medicine evaluation (age 18-39)
    99386Initial comprehensive preventive medicine evaluation (age 40-64)
    99395Periodic comprehensive preventive medicine evaluation (age 18-39)
    99396Periodic comprehensive preventive medicine evaluation (age 40-64)
    G0101Cervical or vaginal cancer screening; pelvic and clinical breast exam
    Q0091Screening Papanicolaou smear collection
    88141Cytopathology, cervical or vaginal (Pap) screen; automated
    Lung cancer screening codesmixed
    71271Low-dose CT for lung cancer screening
    G0296LDCT for lung cancer screening
    Z71.6Tobacco abuse counseling
    Osteoporosis screening codesmixed
    77080Dual-energy X-ray absorptiometry (DXA) bone density, axial skeleton
    77081DXA bone density, appendicular skeleton
    77085Bone density study, single or multiple, hip/leg
    G0130Single energy X-ray absorptiometry (SEXA)
    Z13.820Encounter for screening for osteoporosis
    Prediabetes and type 2 diabetes screening codesmixed
    82947Glucose; quantitative, blood (e.g., fasting)
    83036Hemoglobin; glycosylated (A1c)
    Z13.1Encounter for screening for diabetes mellitus
    R73.03Prediabetes
    Osteoporosis screening procedure codesCPTCovered
    77080Bone density test, DXA; axial skeleton
    77081Bone density test; peripheral
    77085Vertebral fracture assessment
    G0130Single-energy x-ray absorptiometry (DXA)
    Prediabetes/Type 2 diabetes screening CPTCPTCovered
    82947Glucose; quantitative, blood (e.g., fasting)
    83036Hemoglobin; glycosylated (A1c)
    Unhealthy alcohol use screening/counseling codesCPTCovered
    99408Alcohol and/or substance misuse screening and brief intervention, 15 to 30 minutes
    99409Alcohol and/or substance misuse screening and brief intervention, greater than 30 minutes
    G0442Annual alcohol misuse screening, 15 minutes
    G0443Brief face-to-face behavioral counseling for alcohol misuse
    Depression screening codesCPTCovered
    96127Brief emotional/behavioral assessment
    G0444Annual depression screening
    Tobacco cessation counseling codesCPTCovered
    99406Smoking and tobacco use cessation counseling visit, intermediate
    99407Smoking and tobacco use cessation counseling visit, intensive
    Unhealthy drug use screening codesCPTCovered
    G0396Alcohol and/or substance use screening
    G0397Intervention for substance use
    G0442Alcohol misuse screening, 15 minutes
    G0443Brief counseling for alcohol misuse
    G2011Communication technology-based service
    Weight loss / behavioral intervention codesmixedCovered
    97802Medical nutrition therapy; initial assessment and intervention
    97803Medical nutrition therapy; re-assessment
    97804Medical nutrition therapy; group
    G0270Medical nutrition therapy, diagnosis of diabetes
    G0271Medical nutrition therapy, non-diagnosis specific
    S9470Nutritional counseling, dietitian
    99401Preventive medicine counseling, 15 minutes
    99402Preventive medicine counseling, 30 minutes
    99403Preventive medicine counseling, 45 minutes
    99404Preventive medicine counseling, 60 minutes
    1–10 of 13
    1/2
    Hepatitis B screening and blood draw codesCPTCovered
    86704Hepatitis B surface antigen or antibody test
    86705Hepatitis B surface antigen (HBsAg)
    86706Hepatitis B core antibody
    86707Hepatitis B tests (other)
    87340Hepatitis B surface antigen test
    87341Hepatitis B surface antibody test
    G0499Hepatitis B screening
    36415Collection of venous blood by venipuncture
    36416Collection of capillary blood
    Hepatitis C screening codesCPTCovered
    86803Hepatitis C antibody test
    86804Hepatitis C antibody confirmation
    G0472Hepatitis C screening
    Latent tuberculosis infection screening codesCPTCovered
    86480Tuberculosis screening blood test (e.g., T-spot)
    86481TB test, other
    86580TB skin test
    99211Office consultation, minimal
    Falls prevention / therapy codesmixedCovered
    97110Therapeutic procedure, exercise
    97112Neuromuscular reeducation
    97116Gait training
    97161Physical therapy evaluation
    97162Physical therapy evaluation
    97163Physical therapy evaluation
    97530Therapeutic activities
    97750Physical performance test
    G0151Nursing facility; therapeutic procedures
    G0157Therapeutic procedure
    1–10 of 14
    1/2
    Statin primary prevention screening and ASCVD risk codesmixedCovered
    80061Lipid panel
    82465Cholesterol, direct measurement
    83718Lipoprotein, direct
    83719Lipoprotein
    83721Lipoprotein
    83722Lipoprotein
    84478Triglycerides
    G0537Assessment of cardiovascular risk
    G0538Risk management services
    Breast pump allowance — one personal-use electric breast pump per pregnancy
    AllowanceOne personal-use electric breast pump per pregnancy (in-network Home Medical Equipment supplier)
    Included suppliesReplacement supplies necessary for pump operation (power adaptor, tubing, bottles, valves, filters, breast shield)
    Replacement partsReplacement parts provided at no cost as needed (separate from initial purchase)
    Overweight/Obesity BMI percentiles — overweight >=85th–94th percentile; obesity >=95th percentile
    Overweight (children/adolescents)BMI ≥85th to 94th percentile for age and sex
    Obesity (children/adolescents)BMI ≥95th percentile for age and sex
    ActionChildren/adolescents with overweight/obesity should have growth, BP, cholesterol reviewed and be offered/monitored for interventions
    Blood pressure screening age — age 3–17 years
    Recommended agesBlood pressure screening for children and adolescents age 3–17 years
    CodingCPT codes: 93784, 93786, 93788, 93790; diagnosis code R03.0
    Visit contextConsidered part of wellness office visit; requires diagnosis code only if provided outside preventive visit
    Age-based screening thresholds — breast and colorectal screening age ranges
    Breast cancer screening age rangeWomen aged 40–74 years (USPSTF/WPSI); initiate between 40 and 50 and continue through at least 74)
    Colorectal cancer screening age rangeAsymptomatic adults aged 45–75 years (USPSTF: 45–49 Grade B; 50–75 Grade A)
    Interval noteScreening intervals and modality vary by test (mammography biennial to annual; colorectal modalities have differing intervals)
    Age threshold for chlamydia/gonorrhea screening — sexually active women <=24 years (and older women at increased risk)
    Primary age thresholdSexually active women ≤24 years should be screened for chlamydia and gonorrhea
    Older womenOlder women should be screened if at increased risk
    BillingRequires a listed diagnosis code for the preventive benefit to apply (e.g., Z11.3, Z11.8, Z29.81)
    Age range for routine HIV screening — adolescents and adults aged 15 to 65 years
    Routine HIV screening agesAdolescents and adults aged 15 to 65 years
    Additional populationsYounger adolescents and older adults at increased risk should also be screened
    BillingRequires a listed diagnosis code for preventive benefit (e.g., Z11.3, Z11.4, Z11.59, Z29.81)
    Cervical cancer screening intervals — 21–29 every 3 years; 30–65 options include cytology or hrHPV schedules
    21–29 yearsCytology (Pap) every 3 years
    30–65 yearsOptions: cytology every 3 years OR hrHPV testing alone every 5 years OR hrHPV + cytology (cotesting) every 5 years
    PopulationApplies to asymptomatic women with a cervix
    Gestational diabetes screening timing — after 24 weeks gestation (preferably 24–28 weeks)
    TimingScreen asymptomatic pregnant women for gestational diabetes after 24 weeks' gestation (preferably 24–28 weeks)
    Early screeningWPSI: screen earlier at first prenatal visit for women with risk factors for type 2 diabetes or GDM
    CodesGlucose testing CPT: 82947–82952; A1c: 83036/83037; blood draw: 36415/36416
    Rh(D) repeat testing timing — repeat antibody testing at 24–28 weeks for unsensitized Rh(D)-negative women
    Repeat testing timingRepeat Rh(D) antibody testing at 24–28 weeks' gestation for unsensitized Rh(D)-negative women
    Initial testingRh(D) blood typing and antibody testing at first pregnancy-related visit
    CodesScreening/blood draw codes include 80055, 80081, 86850, 86901; blood draw 36415/36416
    Newborn screening age window — age 0 to 90 days
    Age windowNewborn screening recommended for age 0 to 90 days
    Included testsBilirubin screening, metabolic panel (S3620), phenylketonuria testing (84030), and ocular prophylaxis are typically included as part of delivery
    Billing noteRequires a listed diagnosis code for preventive benefit if performed separately
    High BMI threshold for children — >=95th percentile for age and sex
    High BMI definition (children)>= 95th percentile for age and sex
    ActionRefer children/adolescents >=6 years with BMI >=95th percentile to comprehensive intensive behavioral interventions
    Relevant codesMNT and counseling codes: 97802–97804, G0270, G0271, 99401–99404, 0403T, G0446–G0447
    Lung cancer screening eligibility — age 50–80 and >=20 pack-year and current smoker or quit <=15 years
    Age and smoking historyAdults aged 50–80 years with ≥20 pack-year smoking history who currently smoke or quit within past 15 years
    Frequency and discontinuationAnnual LDCT; discontinue after 15 years since quitting or with limited life expectancy/unwilling for curative surgery
    Codes and PAProcedure codes 71271, G0296; normally requires prior authorization; listed diagnosis codes required for preventive benefit
    Osteoporosis screening age threshold — women >=65 or postmenopausal <65 at increased risk
    Primary age thresholdWomen aged ≥65 years
    Younger postmenopausal womenPostmenopausal women <65 years at increased risk (per formal clinical risk assessment) should be screened
    Codes and exclusionsDXA procedure codes 77080, 77081, 77085, G0130; excludes women with history of low-trauma fractures or secondary osteoporosis conditions
    Diabetes screening age threshold — age 35–70 years if overweight or obese
    Age rangeAsymptomatic nonpregnant adults aged 35–70 years
    RiskApplies when overweight or obese
    Interval and codesScreen at recommended interval (once every 3 years); CPT codes 82947, 83036; diagnosis codes Z13.1, R73.03
    Age or BMI thresholds per USPSTF topic — examples across multiple topics
    Examples (osteoporosis)Women ≥65 years or younger if at increased risk per clinical risk assessment
    Examples (diabetes)Adults 35–70 years who are overweight/obese for abnormal blood glucose screening
    Examples (weight/BMI)Adults with BMI ≥30 are candidates for intensive behavioral interventions; children ≥95th percentile referred for intensive interventions
    Prior Authorization

    PrEP Prior Authorization / Prescription

    Prior authorization requirements may apply for HIV pre-exposure prophylaxis (PrEP) services. Prescriptions are required for PrEP injections and medications. Refer to the plan's pharmacy benefit for coverage details and any pharmacy-supplied fees.

    • PrEP procedure and drug codes: 96372, G0012, J0738-J0799, Q0521 (pharmacy supplying fee).
    • Prior authorization and prescription requirements vary by plan — consult the pharmacy benefit.
    Note

    Pharmacy Preventive Benefit — Check Plan Pharmacy

    Refer to the plan's pharmacy benefit for preventive medications and supplements. Examples include folic acid, low-dose aspirin for preeclampsia prevention, and fluoride supplements; some of these items are handled under the pharmacy preventive benefit rather than medical.

    • Folic acid supplements and low-dose aspirin (81 mg) — pharmacy preventive benefit; check coverage and preferred products.
    • Fluoride supplements for young children — handled under the plan's pharmacy preventive benefit; see pharmacy for available options.
    Denial Risk

    Triggers for Denial or Member Cost Share

    Preventive benefit may be denied when services are diagnostic, investigational/experimental, off-label, not medically necessary, provided for non-medical reasons (e.g., travel, employment, school), coded incorrectly, or outside recommended age/interval criteria.

    • Member cost shares will apply for services performed in inappropriate age groups, at intervals outside USPSTF recommendations, for diagnostic or surveillance purposes, or for therapeutic/treatment purposes.
    • Services provided for non-medical reasons (travel, employment, school, licensing, research) are not preventive and may be denied.
    Billing Rule

    Diagnosis Code Required for Preventive Benefit

    For the preventive benefit to apply, providers must include the appropriate listed preventive diagnosis code on the claim, generally in the primary position. Some services (e.g., certain mammography codes, some colorectal screening codes) have specific exceptions noted in the guidance.

    • Bill the preventive diagnosis code in the primary position or as the primary diagnosis pointer when required.
    • Codes that do not require a specific diagnosis for preventive benefit (example: 77063 and 77067 mammography) are noted in the guidance; all other codes generally require a listed diagnosis.
    Denial Risk

    Preventive Benefit Denial Trigger — Conflicting Diagnosis

    Certain preventive benefits will not apply if a contraindicating diagnosis is present. For example, postpartum diabetes screening will not be applied if any diabetes diagnosis code is present in any claim position.

    • Screening for diabetes after pregnancy — the preventive benefit is not applied if a diabetes diagnosis code exists in any position on the claim (e.g., Z86.32 or active diabetes codes).
    Documentation Required

    Coding Requirement for Counseling and Modifier Guidance

    Counseling services provided outside of a preventive (wellness) visit require a listed diagnosis code for the preventive benefit to apply. When counseling is bundled within a wellness visit, a separate diagnosis may not be required.

    • Behavioral and other counseling codes (e.g., 99401-99404, 99411-99412) require a listed preventive diagnosis when billed separately from a wellness visit.
    • When an injection or procedure is billed with a preventive visit, append the appropriate modifier (e.g., -25 or -59) to indicate separate and distinct services where applicable.
    Note

    Immunization Diagnosis Code and Pharmacy Note

    Immunization claims: the ICD-10 code Z23 is requested but not always required for the preventive benefit to apply. When vaccines are available through the pharmacy preventive benefit, refer to the pharmacy benefit for vaccine options and coverage.

    • If an evaluative or preventive service is billed with an injection, append an appropriate modifier (e.g., -25 or -59) to indicate separate services.
    • Refer to the CDC ACIP schedule for recommended vaccine timing and to the plan pharmacy for vaccine availability under the pharmacy preventive benefit.
    Bright Futures periodicity schedule applies birth through 21 years; yearly wellness visit after age 21
    Coding noteWellness visits do not require a diagnosis for preventive benefit, but appropriate diagnosis codes should be submitted
    Immunization diagnosis code — Z23 is the listed code for immunizations (requested but not required)
    ICD-10 codeZ23 is the listed diagnosis code for immunizations (requested but not required for preventive benefit)
    UseRequested on immunization claims though not required for preventive benefit to apply
    Pharmacy noteRefer to plan pharmacy benefit for vaccine options available under the pharmacy preventive benefit
    USPSTF screening intervals — USPSTF recommended intervals and modality options (e.g., mammography, colorectal)
    USPSTF intervalsUSPSTF-recommended screening intervals and modality options (examples: mammography biennial or annual depending on age; colorectal screening modalities and intervals vary)
    Coding dependenceCertain codes may not require diagnosis codes (e.g., 77063, 77067) while others require a listed diagnosis for preventive benefit
    Reference guidanceFollow USPSTF and WPSI recommendations for modality and interval choices
    PrEP — preexposure prophylaxis definition
    DefinitionPrEP: preexposure prophylaxis offered to persons at high risk of HIV acquisition; includes medication administration and monitoring
    RequirementsPrior authorization may apply; prescriptions required for PrEP injections/medications; refer to pharmacy preventive benefit
    MonitoringMonitoring includes kidney testing (82565/82575) and pregnancy testing (81025)
    hrHPV / cotesting — high-risk HPV testing and cotesting options for cervical cancer screening
    hrHPV/cotesting optionsHigh-risk HPV testing and cotesting options for cervical cancer screening: hrHPV alone every 5 years or hrHPV + cytology every 5 years as alternatives to cytology every 3 years
    ApplicabilityApplies to asymptomatic women aged 30–65 with a cervix
    CodesHPV testing CPT codes include 87623–87626 and G0476
    Gestational diabetes screening definition — screening after 24 weeks' gestation (preferably 24–28 weeks)
    DefinitionGestational diabetes screening: screening in asymptomatic pregnant women after 24 weeks' gestation (preferably 24–28 weeks); earlier screening for high-risk women may be recommended
    CodesGlucose testing and A1c CPT codes: 82947–82952, 83036/83037; blood draw 36415/36416
    DocumentationRequires a listed diagnosis code and a pregnancy diagnosis listing code for preventive benefit to apply
    Newborn metabolic and infectious screening — state-recommended newborn screenings included as part of delivery
    ScopeNewborn metabolic and infectious screening: state-recommended newborn screenings (metabolic panel, bilirubin, PKU, ocular prophylaxis) typically included as part of delivery
    Age windowNewborn screenings apply to newborns age 0–90 days
    Separate billingIf performed separately from delivery, listed diagnosis codes are required for the preventive benefit to apply
    Ocular prophylaxis for gonococcal ophthalmia neonatorum — topical ocular medication recommended for all newborns
    RecommendationTopical ocular prophylaxis for all newborns to prevent gonococcal ophthalmia neonatorum (USPSTF Grade A)
    InclusionTypically included as part of delivery
    CodingNo specific procedure code listed in chunk; document notes inclusion with delivery
    LDCT lung cancer screening eligibility definition
    LDCT eligibilityAdults aged 50–80 years with a ≥20 pack-year smoking history who currently smoke or quit within past 15 years
    Frequency/discontinuationAnnual LDCT; discontinue after 15 years since quitting or if limited life expectancy or not candidate for curative surgery
    Coding and PAProcedure codes 71271 and G0296; LDCT normally requires prior authorization
    High risk (for osteoporosis) — postmenopausal women younger than 65 at increased risk per formal clinical assessment
    High-risk definitionPostmenopausal women younger than 65 at increased risk as determined by a formal clinical risk assessment tool (per USPSTF)
    ImplicationThese women should be considered for osteoporosis screening earlier than age 65
    ReferenceUse formal risk assessment tools per USPSTF guidance
    BMI criteria — adults with BMI >=30 are candidates for intensive behavioral interventions
    Adult BMI criterionAdults with BMI ≥30 are candidates for intensive multicomponent behavioral interventions
    Intervention typesMedical nutrition therapy, preventive counseling, behavioral counseling/therapy (codes 97802–97804, G0270/G0271, 99401–99404, 0403T, G0446)
    DocumentationRequires a listed diagnosis code if provided outside a preventive visit