CurrentHighmark Blueshield NenyPolicy N/A

Pediatric obesity preventive benefits and billing

Defines annual covered services for children ages 2–18 with BMI ≥85th percentile, and associated billing/coding guidance for Highmark BlueShield NE/NY members.

Policy Summary

PayerHighmark Blueshield Neny

PolicyPediatric obesity preventive benefits and billing

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionBill covered services for eligible children (age 2–18 with BMI ≥85th percentile) using the obesity diagnosis code (Z68.53 or Z68.54) except when billing cholesterol screening.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2-18eligible member age range

≥85theligibility BMI threshold

4preventive visits/year

unlimitednutrition counseling

1annual lab set

Eligibility and Covered Services

Policy Summary

PayerHighmark Blueshield Neny

PolicyPediatric obesity preventive benefits and billing

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionBill covered services for eligible children (age 2–18 with BMI ≥85th percentile) using the obesity diagnosis code (Z68.53 or Z68.54) except when billing cholesterol screening.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Eligibility and covered services for pediatric obesity

Covered when ALL of the following are met:

Member age 2–18 years (inclusive).

Body mass index (BMI) at or above the 85th percentile for age (pediatric).

ALL of the following

Four preventive health office visits annually: the annual preventive exam plus three follow-up visits specifically for obesity, including blood pressure check.

ALL of the following

Unlimited nutritional counseling visits per year specifically for obesity (covered).

ALL of the following

One set of recommended laboratory tests annually consisting of: cholesterol screening (lipid panel), AND either one Hemoglobin A1c OR one fasting glucose (one glycemic test allowed per calendar year), AND AST, AND ALT.

When billing for the services listed above, use an obesity diagnosis code (Z68.53 or Z68.54).

ALL of the following

Cholesterol screening services are eligible with any routine diagnosis code (obesity diagnosis code not required for cholesterol screening).

Billing and Codes

Office visit codesCPTCovered

99381-99384, 99391-99394

Preventive office visit CPT codes

Nutritional counseling codesCPT | HCPCSCovered

97802-97804, 99401-99404, G0447

Nutritional counseling / preventive counseling codes

Glycemic testing codes (one allowed per year)CPTCovered

83036, 83037	Hemoglobin A1c
82985	Fasting glucose

Liver enzymesCPTCovered

84450	AST
84460	ALT

Required obesity diagnosis codesICD-10Covered

Z68.53	BMI pediatric 85th to <95th percentile
Z68.54	BMI pediatric ≥95th percentile

inv-08: Glycemic test frequency

Glycemic test frequencyEither one Hemoglobin A1c (CPT 83036 or 83037) OR one fasting glucose (CPT 82985) per calendar year.

Eligible codes - Hemoglobin A1c83036, 83037

Eligible code - Fasting glucose82985

Provider Billing and Eligibility Summary

Billing Rule

Provider billing and eligibility summary — pediatric obesity (annual)

Annually, children aged 2–18 with BMI at or above the 85th percentile are eligible for four preventive health office visits (annual exam plus three obesity-focused follow-ups with blood pressure check), unlimited nutrition counseling visits specifically for obesity, and one annual set of recommended labs (cholesterol screening; hemoglobin A1c OR fasting glucose; AST; ALT). Use the applicable obesity diagnosis code (Z68.53 or Z68.54) when billing the listed services except for cholesterol screening, which is eligible with any routine diagnosis code.

Eligibility: age 2–18 with BMI ≥85th percentile.
Covered visits: four preventive health office visits annually (annual exam + three follow-ups) with blood pressure check.
Counseling: unlimited nutritional counseling visits per year specifically for obesity.
Labs: one annual set — cholesterol screening; hemoglobin A1c OR fasting glucose; AST; ALT.
Billing note: use obesity diagnosis code (Z68.53 or Z68.54) when billing these services except cholesterol screening.

Lab Recommendations and Diagnosis Codes

inv-10: Recommended annual labs

Recommended annual lab setCholesterol screening; Hemoglobin A1c OR fasting glucose; AST; ALT.

Cholesterol screening codesLipid panel 80061; Total cholesterol 82465; HDL 83718; Triglycerides 84478; LDL 83721.

Glycemic testing codesHemoglobin A1c 83036, 83037 OR Fasting glucose 82985 (one per calendar year).

Liver enzymesAST 84450; ALT 84460.

inv-11: Obesity diagnosis codes

Z68.53BMI pediatric 85th to <95th percentile (use when billing eligible services).

Z68.54BMI pediatric ≥95th percentile (use when billing eligible services).

Billing requirementAn obesity diagnosis code (Z68.53 or Z68.54) must be used when billing for the listed services except cholesterol screening.