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    v1.0.28
    OpenPayerPolicy UpdatesPreventive Services & ScreeningEmblemHealth Preventive Services Coverage Update |…
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    ModifiedEmblemHealthPolicy N/A

    Preventive Services & Screening — Coverage Criteria

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    Defines EmblemHealth coverage, coding, frequencies and limitations for preventive services and screenings (including immunizations, counseling, breastfeeding equipment and specific screening tests) for commercial and Medicaid members; applies to network providers and non-grandfathered plans unless otherwise noted.

    Policy Summary
    PayerEmblemHealth
    PolicyPreventive Services & Screening — Coverage Criteria
    Policy CodePolicy N/A
    Change TypeMaterial code additions and immunization updates
    Effective DateN/A
    Next Review DateN/A
    Key ActionDocument patient age and append the appropriate preventive ICD-10 diagnosis codes when billing vaccines and preventive services.
    SourceLink
    POLICY UPDATE CHANGES

    Addition of new CPT code 87494 to Chlamydia Screening, Gonorrhea Screening, and PrEP Monitoring and Ongoing Laboratory Testing.

    Addition of new CPT code 90481 to COVID-19 vaccine and administration.

    Addition of Immunization Counseling (without vaccine administration on same date of service) and new CPT codes 90482, 90483, 90484.

    Addition of new CPT code 90683 for RSV vaccine administration (previously added earlier revisions noted).

    Clarified procedure codes and age/frequency limitations for Preventive Screening Examination and Counseling Services Well Child Visits.

    No member cost sharingNon-grandfathered plans coverage
    1 per birthBreast pump limit
    1x/yearPreventive visit frequency
    5yColorectal screening interval
    3yStool DNA testing frequency
    IncludedRSV vaccine codes

    Coverage Criteria and Preventive Benefit Rules

    PPACA-defined preventive services

    Covered when ALL of the following are met

    PPACA preventive service mandate: Service is an evidence-based item/service rated A or B by the USPSTF, an ACIP-recommended immunization, or an HRSA/AAP Bright Futures pediatric preventive service

    Applies to non-grandfathered plans when provided by network physicians

    Determining preventive vs diagnostic coverage

    Classification rule

    Preventive vs Diagnostic determination: Service must be performed for preventive screening (asymptomatic, prior normal within interval, or routine screening recommendation) and reported as preventive to be considered under the preventive benefit; services performed for diagnostic reasons (prior abnormality, symptoms, or shortened interval repeats) are considered non-preventive/diagnostic

    If reported/used for diagnostic purposes the non-preventive medical benefit applies

    Breast pumps and supplies

    Breast pump coverage

    Personal-use electric breast pump: Purchase of one personal-use electric breast pump (HCPCS E0603/E0602) per birth is covered; includes necessary pump supplies and replacement supplies to operate the pump1 per birth

    One pump per birth; multiple infants from same birth do not increase quantity

    Breast pump supplies frequency: Breast pump supply codes (A4281, A4282, A4283, A4284, A4285, A4286, A4288 and A4287 where listed) are covered per preventive benefit1x/pregnancy; A4287: 200 units per 30 days

    Effective dates noted for supply codes (see coding module)

    Colorectal cancer screening frequencies and modalities

    Colorectal cancer screening

    Age and frequency: Screening colonoscopy, CT colonography, and listed colon/colorectal modalities are covered per preventive benefitOnce every 5 years; Ages 45-75

    Includes anesthesia, pathology, and pre-procedure consultation codes as listed

    Stool-based tests: Fecal occult blood tests (82270, 82274) and stool DNA options (e.g., 81528) are covered as preventive optionsOnce every 3 years; Ages 45-85 (Shield: 45+)

    See coding for Cologuard/Cologuard Plus/Shield effective dates and codes

    Colon Cancer Screening (CT Colonography)

    Covered when meeting listed age and frequency limits with specified diagnosis codes

    CT Colonography: Procedure code 74263 with listed preventive ICD-10 diagnosis codes (e.g., Z00.00, Z12.12, Z12.10, Z12.11, Z80.0, Z83.*) is covered as CT colonography for screeningFrequency: once every 5 years; Ages: 45-75 years

    Billing must use the preventive diagnosis codes to receive preventive benefit

    Stool-based Colorectal Cancer Screening

    Covered preventive stool-based colorectal tests with age- and frequency-based limits

    Stool occult blood tests: Procedure codes 82270 and 82274 with listed preventive ICD-10 diagnosis codes are covered for colorectal cancer screeningOnce every 3 years; Ages: 45-85 years

    Must bill with preventive diagnosis codes

    Cologuard and stool DNA tests: Cologuard (81528), Cologuard Plus (0464U effective 9/01/2025) and Shield (0537U effective 1/1/2026) with listed preventive ICD-10 codes are coveredOnce every 3 years; Ages: 45-85 years (Shield: 45+)

    Observe effective dates for new codes

    Contraceptive Services

    Contraceptive counseling, management, and methods coverage rules

    Contraceptive counseling: Procedure codes 99401-99404 (counseling) with ICD-10 Z30.02/Z30.09 are covered; frequency: unlimited; ages: allunlimited

    Counseling included in wellness visits

    Contraceptive management visits: Evaluation/management office visit codes (e.g., 99202-99205, 99211-99215 and ED/urgent codes 99281-99285 as listed) with Group diagnosis codes are coveredunlimited

    Use listed ICD-10 Z30.* codes

    Contraceptive methods and supplies: Contraceptive methods (IUDs, implants, injections, pills, diaphragms) and associated J-codes/CPTs (examples: J7300-J7307, J7296-J7298, J1050, 11976-11983, 58300/S4981) are covered per method-specific frequency limitsmethod-specific (e.g., implants 1x/year, pills up to 12x/year)

    Bill with Z30.x diagnosis codes; frequencies vary by method as listed

    Behavioral and Diabetes Screening

    Behavioral and diabetes screening coverage

    Depression/Anxiety screening: Procedure code 96127 (depression/anxiety screening) with ICD-10 Z13.31/Z13.32/Z13.39 is coveredFrequency: 1x/year for ages 12+; 2x/year ages 8–<12

    Includes postpartum individuals

    Diabetes screening (adults and children): Glucose and HbA1c procedure codes (82947-82952, 83036) with ICD-10 Z00.00/Z00.01/Z13.1/Z86.32 (adults) or Z13.1 (children) are covered1x/year for adults and children; gestational screening per pregnancy guidance

    Gestational diabetes frequency: up to 3x/year as listed

    Dietary Counseling and STI Screening

    Dietary counseling and STI screening coverage

    Dietary counseling for overweight/obese with CVD risk: Procedure codes 97802-97804 and S9470 for medical nutrition therapy are covered for individuals who are overweight/obese with additional cardiovascular risk factorsFrequency: 4x/year

    Use listed ICD-10 diagnostic groups (E08–E13, E66.*, I10, etc.)

    Gonorrhea and chlamydia screening: NAAT and related STI testing codes (e.g., 87494, 87590-87592, 87801, 87850, 0455U) are covered for screening with appropriate ICD-10 screening diagnosis codesFrequency: screening up to 4x/year; pregnancy screening up to 3x/year

    New codes effective 1/1/2026 (87494, 0455U)

    Routine Preventive Screenings

    Various routine preventive screens with age/frequency constraints

    Hearing screening: Procedure codes 92551–92651 with preventive ICD-10 codes are covered for pediatric hearing screeningFrequency: 1x/year; Ages: 0–21 (PCP only)

    See OAE policy for age limits

    Hepatitis B and C screening: Hepatitis B (87340–87341) covered 1x/year ages 18–79; Hepatitis C (86803–86804) covered 1x/year with indicated ICD-10s1x/year

    Follow listed diagnosis codes

    HIV screening codes (86689, 86701–86703, 87389–87391, 87806) are covered as preventive screeningFrequency: unlimited; Ages: all

    Use appropriate preventive diagnosis codes

    HPV DNA screening: HPV DNA testing codes (87624–87626 effective 1/01/2025) are coveredFrequency: 1x/year; Ages: 30–65

    Observe code changes effective 1/01/2025

    Lung cancer screening: Low-dose CT (71271) is covered for lung cancer screening with smoking-related ICD-10 codesFrequency: 1x/year; Ages: 50–80

    See diagnostic linkage for eligibility

    Pap smear cytology codes (88141–88175) with listed ICD-10 screening codes are coveredFrequency: once every 3 years; Ages: 21–65

    Bill with preventive diagnosis codes

    Pregnancy labs and screening panels: Pregnancy-related screening tests and panels (e.g., 81007, 87086, 87088, 80081, 80055, 87340–87341, 86901) are covered per service-specific instructionsFrequency: test-specific (ranges from unlimited to 1x/year)

    Refer to pregnancy preventive instructions and Appendix I for ICD-10 codes

    Osteoporosis Screening (effective dates noted)

    Osteoporosis screening coverage with effective dates

    Osteoporosis Screening (through 12/31/2025): Procedure codes 76977, 77080, 77081 with preventive ICD-10 codes are coveredFrequency: every 23 months; Ages: 60+ (through 12/31/2025)

    Effective until 12/31/2025

    Osteoporosis Screening (effective 1/1/2026): Procedure codes 76977, 77080, 77081 with indicated ICD-10 codes are coveredFrequency: every 24 months; Ages: 65+ (from 1/1/2026). Individuals with prior fragility fractures (Z87.310 AND Z13.820) follow same frequency

    Effective 1/1/2026

    Pregnancy & Pap screening - Covered when service-specific conditions met

    Covered preventive pregnancy and Pap screening when meeting service-specific instructions:

    Pap Smear: Pap smear cytology codes (e.g., 88155, 88164–88167, 88174–88175) with ICD-10 Z00.00/Z01.411/Z12.4 are coveredFrequency: once every 3 years; Ages: 21–65

    Bill with preventive diagnosis codes

    Pregnancy Bacteriuria Screening: Urinalysis and urine culture codes (81007, 87086, 87088) for bacteriuria screening in pregnancy are coveredFrequency: unlimited; Ages: all

    See Appendix I for pregnancy ICD-10 codes

    Pregnancy Blood Count: Pregnancy CBC codes (85025, 85027) are covered for pregnancy screeningFrequency: unlimited; Ages: all

    Use pregnancy screening ICD-10s

    Pregnancy Obstetric Panel: Obstetric panel (80081, includes HIV testing) is covered for pregnancy screeningFrequency: 1x/year; Ages: all

    Bill with appropriate pregnancy ICD-10 codes

    Pregnancy Screening Panel: Pregnancy screening panel (80055 includes Hep B, CBC, Rh(D), Syphilis) is coveredFrequency: 1x/year; Ages: all

    Use pregnancy ICD-10 codes as listed

    PrEP - Covered with specified codes and frequencies

    PrEP counseling, administration, and monitoring coverage

    PrEP Counseling & Administration: PrEP counseling and administration codes (G0012, J0739, G0011, G0013) are covered for prevention of HIV; preventive ICD-10 Z29.81 required for visits on/after 10/01/2023Frequency: unlimited; Ages: all

    Effective 1/01/2024 for listed administration codes

    PrEP Monitoring & Laboratory Testing: Monitoring labs (creatinine 82565/82575 up to 3x/year), pregnancy screening (81025/84702/84703 unlimited for those of childbearing potential), HIV screening (86689,86701–86703,87389–87391,87806 unlimited), and STI testing (listed codes up to 4x/year) are covered with PrEP visits (99202–99215)See item-specific frequencies (e.g., creatinine 3x/year, STI testing 4x/year)

    Cost share waived for USPSTF schedule of testing; append appropriate ICD-10 codes per date of service

    PrEP ICD-10 appending rules: For visits before 10/01/2023 use Z20.6 (and related codes) as described; for visits on/after 10/01/2023 append Z29.81 to all PrEP visits

    Append additional testing diagnosis codes as applicable (Z01.812, Z11.* etc.)

    Behavioral and infectious disease screening - Covered

    Behavioral and infectious disease screening coverage

    Smoking Cessation: Smoking cessation counseling codes (99401, 99402, 99403, 99406, 99407) are coveredFrequency: 8x/year; Ages: all

    Use listed ICD-10 tobacco dependence and history codes

    Syphilis Screening: Syphilis screening codes (86592, 86593) are covered for preventive screeningFrequency: 4x/year; Ages: all

    Use appropriate ICD-10 screening diagnosis codes

    TB Testing: TB testing codes (86480, 86481, 86580) are coveredFrequency: 1x/year; Ages: all

    Use listed ICD-10 codes (R76.11, R76.12, Z11.1, etc.)

    Immunizations & vision screening - Covered per CDC/FDA schedules

    Immunizations and vision screening coverage (FDA/CDC-aligned)

    Immunization administration codes (90460–90474, 90480–90481 etc.) and vaccine product codes are covered when provided per FDA/CDC age and frequency guidanceProvider must follow FDA/CDC age/frequency guidelines

    Adult: 21+; Pediatric: 0–21 (ends on 21st birthday)

    COVID-19 vaccines: COVID-19 vaccine product and administration codes (e.g., 91304, 91318–91323, 90480/90481) are covered when given per FDA/CDC guidance

    90481 is a new admin code effective 1/1/2026; bill with Z23 when applicable

    HPV vaccine codes (90649–90651) are covered for ages 9–26 under preventive benefit; coverage is allowed through age 45 but cost share applies beyond age 26Preventive ages 9–26 (ends on 27th birthday); coverage allowed through 45 with cost share

    Bill with preventive ICD-10 codes

    Influenza vaccines: Influenza vaccine product codes by age group (e.g., 90653, 90656, 90657, 90658, 90660, 90661, 90662, 90673) are covered per seasonal/FDA/CDC indicationsAge-specific as listed per vaccine product

    Follow seasonal effective dates and age bands in coding module

    Vision screening in children: Visual acuity and instrument-based vision screening (99173, 99174, 99177) are covered per preventive instructionsFrequency: 1x/year (instrument based 1–4 years where noted); Ages: 0–21

    PCP-only for specified ages

    Preventive Vaccination Coverage

    Covered when ALL of the following are met

    Age and code match: Patient age must match the Preventive Benefit Instructions for the vaccine CPT/HCPCS code being administeredSee code-specific age bands in coding module (examples: 90653 for ages 65+; 90661 for ages 6 months+; 90660 for ages 2–49)

    Providers must document patient age and use appropriate preventive diagnosis code when billing

    RSV Vaccine Coverage

    Covered when ALL of the following are met

    Guideline adherence: RSV vaccines and related administration codes are covered when provider administration and patient selection adhere to current CDC/ACIP guidelines and the vaccine-specific age indicationsCDC/ACIP

    Specific RSV product age bands noted in coding (e.g., 90380/90381 for ages 0–24 months; 90683 for ages 60+); providers must follow ACIP guidance

    Examinations, screenings, testing, or vaccines are not covered under the preventive benefit when they are required solely for non‑medical administrative reasons such as employment, school/education, sports or camp participation, travel (including travel vaccines), insurance, marriage or adoption, judicial or administrative proceedings/orders, medical research, or to obtain or maintain any type of license. These services may still be covered under another portion of the medical benefit; providers should review the member’s plan and bill under the appropriate benefit if clinically indicated.

    A vaccine (immunization) will not be covered under the preventive benefit if it does not meet the company’s vaccine policy requirements for FDA labeling or if it lacks an explicit ACIP recommendation for routine use published in the CDC Morbidity and Mortality Weekly Report (MMWR). Providers must adhere to FDA/CDC/ACIP guidance when administering and billing vaccines to ensure preventive benefit coverage.

    Preventive benefits apply only when services are billed with the appropriate preventive ICD‑10 diagnosis codes and corresponding procedure codes specified in this guideline. Examples include using the listed preventive diagnosis codes for CT colonography and Cologuard (see the colorectal screening entries). If a service is reported as diagnostic rather than preventive (for example because of symptoms, prior abnormal findings, or shortened interval repeat testing), it will be adjudicated under the non‑preventive medical benefit.

    HPV vaccine preventive coverage is defined for ages 9–26 years (ends on the 27th birthday). Vaccination is allowed through age 45 (until the 46th birthday), but such doses are subject to member cost sharing (i.e., not fully preventive without cost share).

    For EmblemHealth Medicaid plans, reimbursement is limited to procedure codes that appear on the applicable Medicaid fee schedule. Codes not included on the Medicaid fee schedule(s) will be denied, so providers should confirm Medicaid fee schedule inclusion before billing.

    Services that are investigational, experimental, unproven, or not medically necessary are not covered under the preventive benefit. Such determinations should follow applicable medical necessity and coverage policies; services meeting those descriptions should not be billed as preventive.

    Preventive screening tests performed outside the stated age ranges or more frequently than the frequencies listed in this guideline may not be covered as preventive services. Examples include CT colonography performed outside ages 45–75 years or more often than once every 5 years, and Pap smear cytology performed more frequently than once every 3 years for ages 21–65 years.

    The referenced policy chunks do not include any additional explicit statements labeled as 'not medically necessary' beyond the general exclusions and frequency/age‑based limitations already documented elsewhere in the guideline.

    CPT/HCPCS Codes and Frequency Summaries

    General preventive visit CPT codesCPTCovered
    99383Preventive Screening Examination and Counseling Services
    99384Preventive Screening Examination and Counseling Services
    99385Preventive Screening Examination and Counseling Services
    99386Preventive Screening Examination and Counseling Services
    99387Preventive Screening Examination and Counseling Services
    99393Preventive Screening Examination and Counseling Services
    99394Preventive Screening Examination and Counseling Services
    99395Preventive Screening Examination and Counseling Services
    99396Preventive Screening Examination and Counseling Services
    99397Preventive Screening Examination and Counseling Services
    1–10 of 16
    1/2
    Breast pump and suppliesHCPCSCovered
    E0603Personal-use electric breast pump
    E0602Breast pump (unspecified)
    A4281Breast pump supply
    A4282Breast pump supply
    A4283Breast pump supply
    A4284Breast pump supply
    A4285Breast pump supply
    A4286Breast pump supply
    A4288Breast pump supply
    A4287Breast pump supply (Z39.1) optional
    Behavioral counseling for weight managementCPTCovered
    99401Preventive Medicine, Individual Counseling
    99402Preventive Medicine, Individual Counseling
    99403Preventive Medicine, Individual Counseling
    99404Preventive Medicine, Individual Counseling
    Selected specific screening codesmixedCovered
    96110Autism / Formal Developmental Screening
    85014Anemia screening (blood)
    85018Anemia screening (blood)
    99401Breast cancer (BRCA) Genetic testing Counseling/evaluation
    99402Breast cancer (BRCA) Genetic testing Counseling/evaluation
    99403Breast cancer (BRCA) Genetic testing Counseling/evaluation
    99404Breast cancer (BRCA) Genetic testing Counseling/evaluation
    81162BRCA testing
    81163BRCA testing
    81164BRCA testing
    1–10 of 17
    1/2
    Breast imaging and chlamydia testingCPTCovered
    77061Breast tomosynthesis
    77062Breast tomosynthesis
    77063Mammography/tomosynthesis/mammography code (use with mammography)
    77065Diagnostic mammography
    77066Diagnostic mammography bilateral
    77067Screening mammography
    76641Breast ultrasound unilateral
    76642Breast ultrasound bilateral
    77048Additional breast imaging
    0455UChlamydia/Gonorrhea combined testing (new)
    1–10 of 14
    1/2
    Colon and colorectal cancer screening codesCPT|HCPCS|mixedCovered
    00811Anesthesia for lower intestinal endoscopic procedures
    00812Anesthesia for lower intestinal endoscopic procedures
    88305Pathology, gross and microscopic examination
    44388Colonoscopy
    44389Colonoscopy
    44391Colonoscopy
    44392Colonoscopy
    74263CT colonography
    45378Diagnostic colonoscopy
    45380Colonoscopy with biopsy
    1–10 of 12
    1/2
    Colon Cancer Screening (CT Colonography)CPTCovered
    74263CT Colonography
    Screening colonoscopy pre-procedure consultationsCPTCovered
    99202Office/outpatient visit, new patient
    99203Office/outpatient visit, new patient
    99204Office/outpatient visit, new patient
    99205Office/outpatient visit, new patient
    99211Office/outpatient visit, established patient
    99212Office/outpatient visit, established patient
    99213Office/outpatient visit, established patient
    99214Office/outpatient visit, established patient
    99215Office/outpatient visit, established patient
    Colon Cancer Screening (Pathology)CPTCovered
    88305Pathology, surgical pathology, colon cancer screening pathology
    Colon and Colorectal Cancer Screening (stool occult blood)CPTCovered
    82270Occult blood, qualitative
    82274Occult blood, immunoassay
    Colorectal Cancer Screening (stool DNA tests)CPT|HCPCS|OtherCovered
    81528Cologuard stool DNA test
    0464UCologuard Plus lab test (effective 9/01/2025)
    0537UShield™ Guardant Health stool DNA test (effective 1/1/2026)
    Contraceptive counseling, management, and methodsCPT|HCPCS|J-codesCovered
    99401Preventive medicine counseling
    99402Preventive medicine counseling
    99403Preventive medicine counseling
    99404Preventive medicine counseling
    99202Maternity initial visit (see grouping)
    J7306IUD device code example
    J7307IUD device code example
    J7300IUD (copper)
    J7301IUD (Skyla®)
    J7297IUD (Liletta®)
    1–10 of 16
    1/2
    Implantable contraceptive device proceduresCPTCovered
    11976Capsule removal (implantable contraceptive)
    11981Implant insertion
    11982Implant removal
    11983Removal with reinsertion
    Dental Caries Prevention (Oral Fluoride Varnish)CPTCovered
    99188Oral fluoride varnish
    Depression/Anxiety ScreeningCPTCovered
    96127Brief emotional/behavioral assessment screening
    Diabetes Screening (Adults, Children, Gestational)CPT|LaboratoryCovered
    82947Glucose; quantitative
    82948Glucose; quantitative, reagent strip
    82950Glucose tolerance test
    82951Glucose tolerance test
    82952Glucose tolerance test
    83036Hemoglobin A1c
    Dietary Counseling for overweight/obese with CVD riskCPT|HCPCSCovered
    97802Medical nutrition therapy, initial
    97803Medical nutrition therapy, re-assessment
    97804Medical nutrition therapy, group
    S9470Nutrition counseling
    Gonorrhea ScreeningCPT|HCPCS|OtherCovered
    87494Gonorrhea NAAT (new code effective 1/1/2026)
    87590Chlamydia/Gonorrhea testing
    87591Chlamydia/Gonorrhea testing
    87592Chlamydia/Gonorrhea testing
    87801Gonorrhea test
    87850Chlamydia/Gonorrhea antigen
    0455U
    Hearing ScreeningCPTCovered
    92551Screening test, puretone
    92552Pure-tone audiometry
    92553Comprehensive audiometry
    92558Speech recognition threshold
    92587Auditory evoked potentials
    92588Auditory evoked potentials
    92650Assessment of cochlear implant
    92651Evaluation of cochlear implant
    Hepatitis B ScreeningCPTCovered
    87340Hepatitis B surface antigen
    87341Hepatitis B surface antibody
    Hepatitis C ScreeningCPTCovered
    86803Hepatitis C antibody
    86804Hepatitis C testing
    HIV Screening for Adolescents and AdultsCPTCovered
    86689HIV antibody
    86701HIV confirmatory
    86702HIV confirmatory
    86703HIV test
    87389HIV antigen/antibody
    87390HIV antigen/antibody
    87391HIV testing
    87806HIV viral detection
    HPV Screening (DNA)CPTCovered
    87624HPV DNA testing
    87625HPV DNA testing
    87626HPV DNA testing
    0500TDeleted code effective 1/01/2025
    Lead ScreeningCPTCovered
    83655Lead testing
    Lipid ScreeningCPTCovered
    80061Lipid panel
    82465Lipoprotein
    83718Lipoprotein, direct
    83719Lipoprotein, direct
    83721Lipids
    83722Lipoprotein, direct
    84478Triglycerides
    Lung Cancer ScreeningCPTCovered
    71271Low dose CT for lung cancer screening
    Maternity/Antepartum/Global careCPTCovered
    59425Antepartum care only
    59426Antepartum care with delivery
    59400Global maternity
    59510Global maternity, VBAC
    59610Global maternity, repeat cesarean
    59618Global maternity
    Newborn Screening: HypothyroidismCPTCovered
    84437Thyroid stimulating hormone (TSH)
    84443Thyroxine (T4)
    Newborn Screening: PKUCPT|HCPCSCovered
    84030Phenylketonuria (PKU) testing
    S3620Newborn metabolic screening
    Newborn Screening: Sickle Cell DiseaseCPTCovered
    83020Sickle cell screening
    83021Sickle cell screening
    83051Sickle cell testing
    Osteoporosis Screening (codes and effective dates noted)CPTCovered
    76977Ultrasound bone density (portable)
    77080Dual-energy X-ray absorptiometry (DEXA)
    77081Bone density study
    Pap Smear (Cytology)CPTCovered
    88141Pap smear cytology
    88142Pap smear cytology
    88143Pap smear cytology
    88147Pap smear cytology
    88148Pap smear cytology
    88150Pap smear cytology
    88152Pap smear cytology
    88153Pap smear cytology
    88155Pap smear cytology
    88164Pap smear cytology
    1–10 of 15
    1/2
    Pregnancy Bacteriuria ScreeningCPTCovered
    81007Urinalysis, pregnancy bacteriuria screening
    87086Urine culture
    87088Culture, bacterial
    Pregnancy screening panels and Rh typingCPTCovered
    80081Obstetric panel (includes HIV testing)
    86901Rh (D) typing
    80055Pregnancy screening panel (Hep B, CBC, Rh D, Syphilis)
    Pap smear and pregnancy basic screensmixedCovered
    88155Pap smear-related CPT
    88164Pap smear-related CPT
    88165Pap smear-related CPT
    88166Pap smear-related CPT
    88167Pap smear-related CPT
    88174Pap smear-related CPT
    88175Pap smear-related CPT
    81007Pregnancy bacteriuria screening
    87086Pregnancy bacteriuria screening
    87088Pregnancy bacteriuria screening
    1–10 of 12
    1/2
    Pregnancy panels and specific pregnancy testsCPTCovered
    80081Pregnancy obstetric panel (includes HIV testing)
    87340Hepatitis B screening
    87341Hepatitis B screening
    86901Rh (D) typing
    80055Pregnancy screening panel (HepB, CBC, Rh(D), Syphilis)
    PrEP counseling and administration codesHCPCSCovered
    G0012Administration code (PrEP-related injection)
    J0739Injection cabotegravir, 1mg
    G0011Counseling for PrEP
    G0013Counseling for PrEP
    PrEP monitoring, HIV/STI/pregnancy testing, and related labs/visitsmixedCovered
    82565Creatinine
    82575Creatinine
    81025Pregnancy screening urine test
    84702Pregnancy screening
    84703Pregnancy screening
    86689HIV screening
    86701HIV screening
    86702HIV screening
    86703HIV screening
    87389HIV screening
    1–10 of 48
    1/5
    Behavioral, sterilization, TB, vision, venipuncturemixedCovered
    99401Smoking cessation counseling
    99402Smoking cessation counseling
    99403Smoking cessation counseling
    99406Smoking cessation counseling
    99407Smoking cessation counseling
    58340Sterilization procedure
    58565Sterilization procedure
    58600Sterilization procedure
    58605Sterilization procedure
    58611Sterilization procedure
    1–10 of 30
    1/3
    Immunizations and administration codesmixedCovered
    90471Immunization administration (adult/pediatric variants listed)
    90472Immunization administration
    90473Immunization administration
    90474Immunization administration
    90460Pediatric immunization admin
    90480COVID-19 vaccine administration (admin code)
    90481COVID-19 vaccine administration (in conjunction with 90480) - new code effective 1/1/2026
    91304COVID-19 vaccine product
    91318COVID-19 vaccine - Novavax
    91319COVID-19 vaccine - Pfizer-BioNTech
    1–10 of 45
    1/5
    Influenza vaccinesCPTCovered
    90653Fluad (aIIV3) (0.5ml SDS) - Adult: Ages 65 and older
    90656Afluria (IIV3) (0.5ml SDS) - Pediatric: Ages 3 years and older / Adult and Pediatric: Ages 2-49 years (where indicated)
    90657Afluria (IIV3) (5ml MDV) / Fluzone (IIV3) (5ml MDV) - Pediatric: Ages 6-35 months
    90658Afluria (IIV3) (5ml MDV) - Pediatric: Ages 3 years and older
    90660Flumist® (LAIV3) (0.2 ml nasal) - Ages 2-49 years
    90661Flucelvax (ccIIV3) (0.5ml SDS / 5ml MDV) - Ages 6 months and older
    90662Fluzone High-Dose (HD-IIV3) (0.5ml SDS) - Ages 65 and older
    90673Flublok (RIV3) (0.5ml SDS) - Ages 9 and older
    Q2039Influenza virus vaccine, not otherwise specified - Ages 18 and older (where indicated)
    MMR and Meningococcal vaccinesCPTCovered
    90707MMR II®
    90710ProQuad® (MMRV)
    90619MenQuadfi®
    90620Bexsero®
    90621Trumenba®
    90644MenHibrix®
    90733Menomune®
    90734Menactra®, Menveo®
    Pneumococcal vaccinesCPTCovered
    90670Pneumococcal (PPSV23) / Prevnar 13®
    90671Pneumococcal conjugate / Vaxneuvance®
    90677Pneumococcal conjugate / Prevnar20®
    90684Pneumococcal conjugate / CAPVAXIVE™ - Adult (19 years+)
    90732Pneumovax®
    Polio and Rotavirus vaccinesCPTCovered
    90713Polio (IPV) / Ipol®
    90680Rotavirus (RV1, RV5) / Rotateq®
    90681Rotavirus (RV1, RV5) / Rotarix®
    RSV vaccines and administrationCPTCovered
    96380RSV vaccine administration
    96381RSV vaccine administration
    90380Beyfortus™ (RSV)
    90381Beyfortus™ (RSV)
    90678Abrysvo™ (RSV) - follow CDC/ACIP
    90679Arexvy™ (RSV) - follow CDC/ACIP
    90683mRESVIA® (RSV) - Ages 60 and older
    Varicella and ZosterCPTCovered
    90716Varivax® (Varicella vaccine)
    90750Shingrix® (Zoster/Shingles)
    inv-72: BMI threshold for intensive behavioral interventions
    BMI thresholdAdults BMI ≥ 30 — refer to intensive multicomponent behavioral interventions (USPSTF recommendation); associated counseling codes: 99401–99404
    Severe obesity thresholdBMI ≥ 40 — ICD-10 examples: Z68.41–Z68.45 (documentation and appropriate counseling/services)
    Frequency for adult behavioral interventionsPreventive behavioral intervention frequency (adults with BMI ≥30): up to 12x/year for intensive programs as noted in preventive instructions
    inv-73: Colorectal screening age and interval summary
    Primary age rangeAges 45–75 years for colonoscopy, CT colonography and other listed colorectal screening modalities
    Colonoscopy/CT colonography intervalFrequency: once every 5 years for screening colonoscopy, CT colonography and related pre-procedure consultations
    Stool DNA test interval and ageStool DNA tests (Cologuard 81528, Cologuard Plus 0464U, Shield 0537U): once every 3 years; ages 45–85 (Shield: ages 45+)
    inv-74: Colon Cancer Screening (CT Colonography) Age
    CT colonography age bandAges 45–75 years
    CT colonography frequencyOnce every 5 years
    Preventive diagnosis linkageUse preventive ICD-10 codes listed (e.g., Z12.12, Z12.10) when billing to ensure preventive benefit
    inv-75: Stool-based colorectal screening frequency
    Stool-based screening frequencyOnce every 3 years for fecal occult blood (82270, 82274) and stool DNA tests (81528, 0464U, 0537U)
    Age limits for stool occult blood testsAges 45–85 years for fecal occult blood tests (82270, 82274)
    Age limits for stool DNA testsCologuard (81528, 0464U) ages 45–85; Shield (0537U) preventive instructions: ages 45 and older
    inv-76: Pap smear frequency
    Pap smear frequency (cytology)Once every 3 years for cytology (CPT codes 88141–88175) for ages 21–65
    Applicable CPT codesCytology codes listed include 88141–88175 (select codes 88155, 88164–88167, 88174, 88175 referenced)
    Diagnostic vs preventiveReport as preventive (use preventive ICD-10 codes such as Z12.4 or Z00.00/Z00.01) to receive preventive benefit; more frequent testing for diagnostic indications is considered non-preventive
    inv-77: Lung cancer screening age and frequency
    Lung cancer screening age bandAges 50–80 years
    Lung cancer screening frequencyLow-dose CT (procedure code 71271) — once per year
    ICD-10 and risk linkageScreening tied to smoking-related diagnosis codes as listed in the lung cancer screening entry
    inv-78: Pap smear frequency (alternate reference)
    Pap smear frequency (alternate ref)Once every 3 years (1x/3 years) for ages 21–65 using cytology CPT codes 88141–88175
    Preventive diagnosis codesTypical preventive ICD-10 codes include Z00.00, Z00.01, Z01.411, Z01.419, Z12.4
    Frequency noteTesting more frequently than 1x/3 years for ages 21–65 is considered diagnostic and billed under the non-preventive benefit
    inv-79: Pregnancy obstetric panel frequency
    Pregnancy obstetric panel frequencyObstetric panel (CPT 80081, includes HIV testing): once per year during pregnancy (Preventive Benefit Instructions)
    Pregnancy screening panel frequencyPregnancy screening panel (CPT 80055, includes Hep B, CBC, Rh(D), Syphilis): once per year
    Pregnancy bacteriuria and CBCBacteriuria screening (81007, 87086, 87088) and pregnancy blood counts (85025, 85027): frequency unlimited as clinically indicated
    inv-80: Smoking cessation visits frequency
    Smoking cessation visit allowanceUp to 8 visits per year for smoking cessation counseling (CPT 99401–99404, 99406, 99407)
    Applicable CPT codesSmoking cessation codes include 99401, 99402, 99403, 99406, 99407
    DocumentationUse appropriate smoking-related ICD-10 codes (e.g., F17.x, Z87.891) when billing preventive smoking cessation services
    inv-81: Syphilis screening frequency
    Syphilis screening frequencyUp to 4 times per year for syphilis screening (CPT 86592, 86593)
    Applicable agesFrequency applies to all ages as listed in preventive instructions
    Associated ICD-10 codesUse Z00.00/Z00.01 for adult screening and pediatric codes Z00.121/Z00.129 as applicable
    inv-82: Vision screening in children frequency
    Vision screening frequency (children)Once per year for children ages 0–21 (visual acuity CPT 99173)
    Instrument-based screeningInstrument-based vision screening (CPT 99174, 99177): frequency 1x/year for ages 1–4 years as noted
    Provider limitationPreventive vision screening for children 0–21 is PCP-only per the preventive benefit instructions
    inv-83: Age limits for vaccines (age bands referenced)
    Vaccine age bands vary by codeAge limits are specified per vaccine CPT/HCPCS code (examples: influenza high-dose 90653 for ages 65+; influenza 90661 for ages ≥6 months; rotavirus 90681 for ages 0–8 months; RSV product codes with specific pediatric/adult ages)
    RSV age examplesRSV vaccine entries (CPT/HCPCS 90380, 90381, 90678, 90679, 90683) include ages 0–24 months for some products and age 60+ for others (see coding entries) — follow Preventive Benefit Instructions
    Influenza age examplesInfluenza product codes listed with age-specific guidance (e.g., 90656 pediatric 3+; 90657 pediatric 6–35 months; 90660 ages 2–49)

    Provider Billing, Documentation, and Authorization Guidance

    Prior Authorization

    Prior authorization may be required for BRCA genetic testing

    BRCA genetic testing counseling/evaluation may require prior authorization. Verify PA requirements before ordering genetic testing to avoid delays.

    • Affected codes: 81162, 81163, 81164, 81165, 81166, 81167, 81212, 81215, 81216, 81217
    • Preventive frequency: once per lifetime; ICD-10: Z15.01, Z15.02, Z80.3, Z80.41, Z85.3, Z85.43
    Prior Authorization

    Confirm prior authorization for imaging and maternity-related services

    Confirm whether prior authorization is required for imaging or maternity-related preventive services per member plan — check plan-specific PA rules prior to scheduling.

    • Examples: screening colonoscopy pre-procedure consults (99202-99215 series) and newborn/specialty screens may have plan-level PA rules
    • Verify PA for services effective dates noted in code lists (e.g., codes with future effective dates)
    Billing Rule

    PrEP counseling and administration — coding and diagnosis requirements

    PrEP counseling and administration is a covered preventive service (effective 1/01/2024). Use required administration and counseling codes and append mandated diagnosis codes on visits on/after 10/01/2023.

    • Counseling/admin codes: G0011, G0013, G0012; Injection cabotegravir: J0739
    • PrEP visits: 99202-99215
    • Required diagnosis: Z29.81 (must be appended for visits on/after 10/01/2023); earlier visits use Z20.6 and Z20.2 as specified
    • Append additional testing/visit codes as applicable: Z01.812, Z11.3, Z11.4, Z11.59, Z20.2, Z20.5, Z20.6, Z77.21
    Prior Authorization

    Prior authorization summary for vaccines and administration

    Prior authorization may be required for certain vaccines and vaccine administration depending on plan rules and FDA/ACIP recommendations. Document age and applicable preventive diagnosis when administering vaccines.

    • Follow CDC/ACIP and FDA licensure guidance for age and frequency (e.g., RSV vaccine age limits, pneumococcal, polio, rotavirus)
    • Document patient age and preventive diagnosis code when billing vaccine administration
    • Check PA for non-routine or off-label vaccine use
    Documentation Required

    Preventive vs Diagnostic reporting guidance

    Distinguish preventive versus diagnostic intent when reporting services. Use preventive diagnosis codes and intervals when the service meets preventive criteria; otherwise bill under the non-preventive medical benefit.

    • Preventive: asymptomatic, within recommended interval, or prior normal diagnostic result leading to routine screening
    • Diagnostic: symptoms, prior abnormal results requiring follow-up, shortened-interval repeats, or outside guideline population
    Denial Risk

    Medicaid fee schedule denial risk

    EmblemHealth Medicaid plans reimburse only codes listed on the Medicaid fee schedule — codes not on the fee schedule will be denied.

    • Verify code inclusion on the member's Medicaid fee schedule before billing
    • Risk of denial for codes absent from Medicaid fee schedules
    Denial Risk

    Frequency limits and denial risk for out-of-interval services

    Frequency limits apply to many preventive services; billing for services outside stated intervals risks denial. Confirm the allowed frequency and patient age prior to performing the service.

    • Examples: screening colonoscopy consults and stool occult blood testing have specified frequencies (see code lists)
    • Services billed outside the listed frequency or age ranges may be denied
    Documentation Required

    Immunization guideline adherence requirement

    When administering immunizations, providers must adhere to FDA/CDC age and interval guidance (ACIP). Non-adherence may result in coverage denial.

    • Follow CDC Child, Adolescent & Catch-up and Adult Immunization Schedules
    • Document adherence to age/frequency rules in the medical record
    Documentation Required

    Adhere to CDC/ACIP guidance (RSV and influenza specific note)

    For RSV and other vaccines, adhere to CDC/ACIP recommendations and document patient age; follow specified age limits for administration.

    • RSV vaccine example: Beyfortus (90380/90381) indicated for ages 0–24 months (ends on 2nd birthday); Abrysvo (90678) per CDC guidance
    • Document preventive diagnosis and patient age when billing

    Policy Background and Scope

    This policy implements the Patient Protection and Affordable Care Act (PPACA) preventive service mandates for non‑grandfathered plans and aligns coverage with authoritative recommendations. Covered preventive services include items rated A or B by the USPSTF, immunizations recommended by ACIP/CDC, and HRSA/AAP Bright Futures pediatric preventive services. The guideline distinguishes preventive services (performed for asymptomatic individuals within recommended intervals and billed as preventive) from diagnostic services (performed for symptoms, prior abnormal findings, or shortened‑interval testing), and requires appropriate preventive coding and adherence to the applicable age and frequency criteria to qualify for the no cost‑sharing preventive benefit.

    Key Definitions

    inv-101: Preventive service definition
    DefinitionServices performed on an asymptomatic person within recommended intervals, or routine screening with prior normal findings, and reported as preventive to be covered under the preventive benefit
    Coverage linkagePreventive services include USPSTF A/B recommendations, ACIP-recommended immunizations, and HRSA/AAP Bright Futures pediatric preventive services
    Billing requirementService must be reported as preventive (use applicable preventive ICD-10 codes) to be considered under the preventive benefit; otherwise treated as diagnostic
    inv-102: Diagnostic service definition
    DefinitionService performed to evaluate symptoms, prior abnormal findings, or when repeat testing is indicated at intervals shorter than recommended preventive intervals — considered diagnostic and billed under non-preventive benefit
    ExamplesDiagnostic reasons include prior abnormal studies requiring follow-up, symptoms requiring further evaluation, or not meeting preventive population criteria
    ConsequenceServices performed for diagnostic purposes are not eligible for the preventive benefit and should be billed under the applicable medical benefit
    inv-103: Colorectal cancer screening (stool DNA/Cologuard/Shield) definition
    DefinitionNoninvasive stool-based DNA tests used for colorectal cancer screening (e.g., Cologuard CPT 81528; Cologuard Plus 0464U effective 9/01/2025; Shield 0537U effective 1/01/2026)
    Interval and agesUsed for screening once every 3 years for ages 45–85 (Shield: ages 45 and older)
    Preventive codingBill with preventive ICD-10 codes Z12.10/Z12.11/Z12.12 and procedure codes listed to apply the preventive benefit
    inv-104: Pap smear definition
    DefinitionPap smear refers to cytology testing using CPT codes 88141–88175 for cervical cancer screening
    Recommended interval and agesRecommended once every 3 years for ages 21–65 when billed as preventive
    Billing noteUse preventive ICD-10 codes (e.g., Z12.4, Z00.00/Z00.01) to ensure preventive benefit; more frequent testing for abnormal results is diagnostic
    inv-105: PrEP Monitoring and Testing definition
    DefinitionPrEP Monitoring and Testing includes counseling/administration (G0011, G0012, G0013, J0739) and associated periodic lab testing and visits for persons receiving PrEP
    Typical monitoring tests & frequencyCreatinine (82565, 82575) up to 3x/year; pregnancy screening (81025, 84702, 84703) unlimited for those of childbearing potential; HIV screening and STI testing per sections (many tests unlimited or up to 4x/year)
    Coding & ICD-10 appendingPrEP visits before 10/01/2023 used Z20.6/Z20.2; for visits on/after 10/01/2023 append Z29.81 to all PrEP visits as specified
    inv-106: Preventive Benefit Instructions (vaccine age groups)
    DefinitionPreventive Benefit Instructions: age-group and preventive-use guidance associated with each vaccine CPT/HCPCS code as listed in the policy (follow code-specific age/frequency guidance)
    Provider responsibilityProviders must document patient age and use the Preventive Benefit Instructions when administering vaccines to determine preventive coverage
    AlignmentInstructions align with FDA licensure and CDC/ACIP recommendations as detailed in the immunization sections
    inv-107: ACIP/CDC adherence definition
    DefinitionACIP/CDC adherence means providers must follow current CDC/ACIP vaccine age and frequency guidelines (e.g., RSV, certain influenza codes) to qualify for preventive coverage
    Policy implicationFailure to adhere to FDA/CDC/ACIP age or frequency guidance may affect preventive billing or result in coverage restrictions
    ExamplesRSV vaccine entries explicitly require adherence to CDC/ACIP; influenza vaccine product codes include age-specific preventive instructions

    Revision History and Material Changes

    2026-02-09code additionsLatest

    Added CPT 87494 to Chlamydia/Gonorrhea screening and PrEP monitoring; added CPT 90481 to COVID-19 vaccine administration; added immunization counseling codes 90482, 90483, 90484.

    2025-10-14code addition

    Added HCPCS code A4288 to Breast Pump Supplies effective 10/01/2025.

    2025-09-18code addition

    Added COVID-19 vaccine product code 91323 effective 08/27/2025.

    2025-09-04code additions and vaccine update

    Added 0455U to Chlamydia/Gonorrhea screening and PrEP monitoring; added colorectal stool DNA code 0537U (Shield™); updated 2025-2026 influenza vaccine listings.

    2025-06-09clarification

    Clarified procedure codes and age/frequency limitations for Preventive Screening Examination and Well Child visit services; updated ACIP link in Introduction.

    2025-04-28clarification

    Clarified that EmblemHealth Medicaid plans reimburse codes only if found on the Medicaid fee schedules.

    2022-06-14vaccine and age-limit updates

    Added dengue vaccine CPT 90587 and pneumococcal conjugate codes 90671 and 90677 with associated age/benefit limits; updated zoster age limit and removed CPT 90736.

    2022-01-24frequency update

    Updated medical nutrition CPT codes 97802/97803/97804 frequency to 4 times per year effective 01/01/2020.

    2021-10-15contraceptive code updates

    Added two new contraceptive codes effective 10/01/2021 and noted deletion of J7303 effective 09/30/2021.

    2021-10-01screening ICD-10 updates

    Updated Chlamydia and HIV screening ICD-10 code lists to include additional Z-codes for screening.

    Policy Summary
    PayerEmblemHealth
    PolicyPreventive Services & Screening — Coverage Criteria
    Policy CodePolicy N/A
    Change TypeMaterial code additions and immunization updates
    Effective DateN/A
    Next Review DateN/A
    Key ActionDocument patient age and append the appropriate preventive ICD-10 diagnosis codes when billing vaccines and preventive services.
    SourceLink
    On This Page
    Coverage Criteria and Preventive Benefit RulesCPT/HCPCS Codes and Frequency SummariesProvider Billing, Documentation, and Authorization GuidancePolicy Background and ScopeKey DefinitionsRevision History and Material Changes

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