Kaiser Permanente preventive services Coverage Update

Covered Preventive Services & Criteria

Covered with criteria

Covered preventive services and billing guidance

In-network preventive coverage: Preventive services recommended by USPSTF (Grade A/B), Bright Futures (AAP), ACIP/CDC, HRSA, and applicable state/federal laws are covered with no member cost share when rendered by an in-network provider

Members should check Evidence of Coverage for plan-specific variations; grandfathered/PPACA-exempt groups may differ

Co-billed services: If non-preventive services are provided during a preventive visit, applicable member cost shares apply and documentation must support separate billing; modifier 33 may be used when ACA preventive coverage is mandated and no other code designates the service as preventive

Plan authorization requirements still apply for services needing prior authorization

Colorectal screening ages: Colorectal cancer screening covered per USPSTF: ages 45 to 75 recommended; selective screening 76 to 85Ages 45-75

Includes FOBT/FIT, screening colonoscopy, sigmoidoscopy, sedation, pathology and related services

Syphilis screening (pregnancy)

Covered per USPSTF recommendations in these excerpts when indicated:

Syphilis in pregnancy: USPSTF recommends early screening for syphilis infection in all pregnant women and screening persons at increased riskpregnancy; at first prenatal visit/early in pregnancy

Recommendation cited from USPSTF (Sept 2018/Sept 2022)

Hepatitis B screening (pregnant women)

Covered preventive services with billing notes:

Hepatitis B screening (pregnant): USPSTF recommends screening for hepatitis B virus (HBV) infection in pregnant women at their first prenatal visit.first prenatal visit

Procedure codes 87340 and 87341 listed; payable as preventive with any pregnancy or maternity diagnosis.

Abdominal aortic aneurysm screening (men)

AAA one-time screening: USPSTF recommends one-time abdominal aortic aneurysm screening by ultrasonography in men ages 65–75 who have ever smoked.men 65–75 who have ever smoked

Procedure codes for ultrasound include 76775, 76700, 76705, 76770, 76706.

Iron deficiency anemia screening

Iron deficiency anemia screening (children & pregnant women): Bright Futures recommends screening for iron deficiency anemia in young children; USPSTF concludes evidence is insufficient to assess balance of benefits and harms of screening pregnant women to prevent adverse maternal and birth outcomes.young children per Bright Futures; pregnant women: evidence insufficient

Procedure codes 85013, 85014, 85018 listed for screening; extensive pregnancy diagnosis code list included.

Behavioral counseling and mental health screening

Behavioral counseling for diet/physical activity & depression/anxiety screening: USPSTF recommends offering or referring adults with cardiovascular risk factors to behavioral counseling interventions and recommends screening for depression and anxiety in adults (including pregnant and postpartum persons).adults with CVD risk factors; adults (including pregnant/postpartum) for depression/anxiety

Procedure and counseling codes listed (e.g., 97802-97804, G0270, G0444, 96127, 96160, 96161).

Preventive service coverage criteria (selected)

Covered preventive services when performed per guideline recommendations; many services marked payable regardless of medical diagnosis code.

Depression screening in children/adolescents: USPSTF recommends screening for major depressive disorder in children and adolescents (applies to persons 18 years or younger without diagnosed depression or signs/symptoms).age <=18

Procedure codes include 96160, 96161, 96127; G0444 payable as preventive regardless of medical diagnosis code.

Obesity screening (adults): USPSTF recommends offering referral for intensive multicomponent behavioral interventions for adults with BMI >=30.BMI >=30

Procedure codes include G0447, G0473, 97802-97804; payable as preventive regardless of medical diagnosis code.

Rh(D) incompatibility screening (pregnancy): USPSTF strongly recommends Rh(D) blood typing and antibody testing for all pregnant women at the first prenatal visit and repeated antibody testing at 24–28 weeks for unsensitized Rh(D)-negative women unless biological father is Rh(D)-negative.

Well-Woman Visit Coverage

Covered preventive services for well-woman visits

Well-woman visit coverage: Annual preventive visit across the lifespan to deliver and coordinate recommended preventive services; primary purpose is preventive care and many well-woman procedure codes are payable as preventive regardless of medical diagnosis code.

HRSA/WPSI guidance referenced; procedure codes include 99383–99387, 99393–99397 and counseling codes 99401–99404.

Gestational Diabetes Screening

Gestational diabetes screening

GDM screening timing: Screen asymptomatic pregnant persons for gestational diabetes at 24 weeks of gestation or after (preferably 24–28 weeks); screen high-risk individuals earlier (GDM before 24 weeks ideally at first prenatal visit).>=24 weeks (preferably 24–28 weeks); earlier if high risk

Procedure codes include 82947–82952 and 83036; payable as preventive with pregnancy/maternity diagnosis.

Hypertensive Disorders of Pregnancy: Screening

Hypertensive disorders of pregnancy screening

Blood pressure monitoring: Screen for hypertensive disorders of pregnancy with blood pressure measurements throughout pregnancy.throughout pregnancy

Payable as preventive with any pregnancy or maternity diagnosis; USPSTF recommendation (Release Date: September 2023).

Pediatric High BMI Interventions

High BMI in children and adolescents

Behavioral interventions: Provide or refer children and adolescents aged >=6 years with BMI at or above the 95th percentile for age and sex to comprehensive, intensive behavioral interventions.>=95th percentile for age and sex

Procedure codes include 96156, 96158, 96159, 97802–97804; USPSTF recommendation (June 2024).

Mobile Application (Contraceptive) Coverage

Mobile contraceptive applications

Mobile app coverage: FDA-approved/cleared contraceptive mobile medical applications (examples: Natural Cycles, Clue Plus) are identified; if a provider prescribes an FDA-approved/cleared contraceptive mobile app as medically indicated, billing codes apply and members will pay according to plan rules.

Procedure codes include A4267–A4269, J7299, 99199, A9293; some codes billed with modifier 33 or specific diagnosis pairings for preventive payment.

Breastfeeding Services and Supplies

Breastfeeding services and supplies

Breastfeeding supplies coverage: Breastfeeding counseling, education, equipment and supplies during antenatal, perinatal, and postpartum periods are covered; specific HCPCS procedure codes S9443 and HCPCS E0602–E0604 and supply codes (A4281–A4288, A9900) are listed and payable as preventive as indicated.

HRSA/WPSI recommendations referenced; diagnosis codes related to postpartum/breastfeeding listed.

Covered preventive services (selected)

Covered preventive services and conditions where preventive payment applies include (selected items from document):

Breastfeeding services: Counseling, education, breastfeeding equipment and supplies during antenatal, perinatal, and postpartum periods to support initiation and maintenance of breastfeeding; many HCPCS and CPT codes listed and payable as preventive as indicated.

See breastfeeding code groups and HRSA/WPSI guidance.

Hepatitis C screening: USPSTF recommends screening for HCV infection in adults aged 18 to 79 and persons at high risk; CPT codes 86803 and 87521 listed.

One-time screening for those born 1945–1965 noted; payable as preventive as indicated.

Lung cancer screening: Annual low-dose CT (LDCT) screening for eligible adults per USPSTF; updated criteria effective 03/09/2021 expand eligibility to adults aged 50–80 with a 20+ pack-year history who currently smoke or quit within 15 years; discontinue screening after 15 years since quitting or if life expectancy/ability for curative surgery is limited.eligibility per USPSTF (age and pack-year criteria)

Preventive Visit Coverage

Covered when submitted as preventive with listed CPTs:

Preventive visit CPTs payable: When CPTs 99384, 99385, 99386, 99394, 99395, or 99396 are submitted they are payable as preventive regardless of medical diagnosis.

Applies to Commercial Preventive Care Services preventive medicine visit codes.

Screening Tests Coverage

Services listed with CPTs and associated diagnosis codes are classified under Commercial Preventive Care Services and noted as covered preventive services (many diabetes-related and cardiovascular screening codes included).

Screenings: Retinopathy screening (CPTs 92227–92250), A1C testing (83036), INR testing (85610, 85611), LDL testing (83695–83722 range), and PSA testing (CPTs 84152–84154) are included in the preventive care listings with associated diagnosis codes indicating diabetes, liver disease, heart disease, or preventive screening contexts.

Procedure and diagnosis code groupings and IRS Expanded Preventive Services guidance referenced.

Prostate Cancer Screening

Prostate cancer screening payable: Prostate cancer screening CPT codes 84152–84154 listed; diagnosis codes Z00.00, Z00.01, Z12.5, Z80.42 are noted and prostate cancer screening is stated as payable as preventive regardless of medical diagnosis code.

Procedure and diagnosis codes listed in preventive services section.

Risk Assessment for Sudden Cardiac Arrest and Sudden Cardiac Death

SCA/SCD risk assessment age range: Risk assessment for sudden cardiac arrest and sudden cardiac death (CPTs 96160, 96161) is identified to occur from ages 11 to 21 to align with Bright Futures/AAP guidance.ages 11-21

Bright Futures/AAP policy alignment cited.

Venipuncture

Venipuncture for preventive services: Collection of venous blood by venipuncture (CPT 36415) is applicable to any covered preventive service in this document that requires venipuncture.

CPT 36415 listed as applicable across preventive services.

Many Kaiser Foundation Health Plan of Washington POS and PPO plans do not provide preventive care coverage for services rendered out-of-network. Exceptions are noted for screening mammography, which may be covered at the same out-of-network benefit level as other covered out-of-network services; members should confirm plan-specific details in their Evidence of Coverage. Preventive services rendered by an in-network provider are covered at 100% under the ACA requirement; plan authorization rules still apply for services that require prior authorization and non-preventive services provided during a preventive visit may be subject to member cost shares.

The USPSTF has concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening for iron deficiency anemia in pregnant women to prevent adverse maternal health and birth outcomes. Bright Futures recommends screening in young children, and procedure codes for testing (e.g., CBC/CBC with differential) are listed, but for pregnancy the guideline conclusion is insufficient evidence and no preventive benefit determination is made by USPSTF for routine antenatal screening to prevent adverse outcomes.

For cervical cancer screening, the policy follows HRSA/WPSI and USPSTF guidance: women aged 21–29 should receive cervical cytology (Pap test) every 3 years, and women aged 30–65 may be screened with cytology alone every 3 years or with hrHPV testing (alone or cotesting) at intervals up to 5 years per age-specific guidance. Importantly, women at average risk should not be screened more than once every 3 years when cytology is used.

FDA-approved or cleared contraceptive mobile medical applications (examples identified in the policy include Natural Cycles and Clue Plus) are listed among preventive-related procedure codes. If a provider prescribes an FDA-approved/cleared contraceptive mobile application as medically indicated, the policy indicates that members will pay for the prescribed app and that specific billing rules, diagnosis codes, and modifier pairings apply for preventive payment.

Lung cancer screening with annual low-dose CT (LDCT) is covered for eligible members per USPSTF criteria; the guidance also specifies when screening should be discontinued. Screening should be stopped once a person has not smoked for 15 years, or when a health problem substantially limits life expectancy or the ability or willingness to undergo curative lung surgery. The policy reflects the updated USPSTF eligibility thresholds effective 03/09/2021 and includes billing codes for LDCT.

The document does not frame iron deficiency anemia screening in pregnancy as ‘‘not medically necessary.’’ Rather, the USPSTF conclusion cited in the policy is that evidence is insufficient to determine the balance of benefits and harms for routine screening of pregnant women to prevent adverse maternal or birth outcomes.

The policy specifies that cotesting (cytology plus hrHPV) is not recommended for women younger than 30 years; for ages 21–29, screening should be performed using cervical cytology alone at intervals of every 3 years.

The source excerpts do not include explicit statements labeling services as ‘‘not medically necessary’’ for the items shown; instead, many entries describe recommended screening intervals, payable-as-preventive billing rules, or indicate insufficient evidence where applicable.

Procedure, Diagnosis & Modifier Codes

General visit codes with preventive modifier guidanceCPT

99202-99215, 99417, G2212, 97802-97804, 99241-99245

E/M and related visit codes; modifier 33 may be added when ACA preventive coverage applies

Breast cancer screening CPTCPTCovered

77063, 77067

Screening mammography procedure codes

Breast imaging/pathologymixedCovered

77065, 77066, 10004-10006, 10021, 19081, 19083, 19100, 88172, 88173, 88177, 88305

Additional imaging and pathology codes related to mammography/screening workup

Chlamydia/gonorrhea screening CPT/othermixedCovered

86631, 86632, 87110, 87270, 87320, 87490, 87491, 87492, 87810

Chlamydia and gonorrhea screening tests

Infectious disease testingCPTCovered

87590, 87591, 87592, 87850, 87801

Infectious disease testing codes

Colorectal cancer screening codesmixedCovered

44388, 44389, 44392, 44401, 45300, 45305, 45308, 45309, 45315, 45320, 45330, 45331, 45333, 45338, 45346, 45378, 45380, 45381, 45382, 45384, 45385, 45388, 45390, 44394, 74263, 74261, 74262	Colorectal cancer screening-related procedures (colonoscopy, sigmoidoscopy, imaging)
82274, G0500, 88304, 88305, 99151-99157, 99242-99245	Pathology, counseling/visit, sedation and related services for colorectal screening

HIV screening codesmixedCovered

G0432, G0433, G0435, G0475, 86701, 86702, 86703, 86689, S3645, 87806, 87534, 87535, 87390, 87391, 87389

HIV screening procedure and lab codes

Osteoporosis screening codesCPTCovered

77078, 77080, 77081, 77085, 76977, 78350, 78351, G0130

Bone density and related imaging codes for osteoporosis screening

Newborn PKU screeningCPTCovered

84030, 84035, S3620

Newborn phenylketonuria screening codes

Pregnancy-related preventive codeCPTCovered

0210U

Procedure code listed with pregnancy/maternity diagnosis codes

Behavioral counseling codesCPTCovered

99401-99404, 99408-99412, G2011, G0396, G0397, G0442, G0443, H0005	Alcohol misuse screening and behavioral counseling codes
99406, 99407, G0436, G0437, S9453	Tobacco use counseling codes

Diabetes screening codesCPTCovered

82947, 82948, 82950, 83036

Prediabetes and Type 2 diabetes screening (glucose/HbA1c)

Procedure codes (selected)CPT

0210U

Procedure code listed under Pregnancy screening (syphilis context)

Pregnancy/Maternity diagnosis codes (selected)ICD-10

Z01.411	Pregnancy/maternity diagnosis code
Z01.419	Pregnancy/maternity diagnosis code
Z11.3	Screening for infections
Z11.4	Screening for other infectious and parasitic diseases
Z11.8	Other screening for infectious and parasitic diseases
Z12.4	Screening for malignant neoplasm of cervix
Z12.72	Screening for other malignant neoplasm
Z20.2	Contact with and (suspected) exposure to infections
Z20.5	Contact with and exposure to viral hepatitis
Z20.6	Contact with and exposure to HIV

Abdominal Aortic Aneurysm - Procedure codesCPTCovered

76775	Ultrasonography procedure code for AAA screening (example group)
76700	Ultrasonography abdomen complete/limited
76705	Ultrasound abdomen
76770	Ultrasound vascular
76706	Ultrasound abdomen complete

Iron deficiency anemia - Procedure codesCPTCovered

85013	Blood count procedures for iron deficiency anemia screening
85014	CBC automated and differential
85018	Blood count automated

Hepatitis B screening (pregnant women) - Procedure codesCPTCovered

87340	Hepatitis B surface antigen test
87341	Hepatitis B surface antigen test (alternate)

BRCA testing - Procedure/genetic codesCPTCovered

81212	BRCA1/BRCA2 testing (example listed)
81215	BRCA testing code
81162	BRCA sequencing/analysis

Behavioral counseling - Procedure codesmixedCovered

97802	Medical nutrition therapy; initial assessment
97803	Medical nutrition therapy; re-assessment
97804	Medical nutrition therapy; group session
G0270	Behavioral counseling for CVD prevention
G0271	Behavioral counseling for diet

Vision screening (children) - Procedure codesCPTCovered

99172	Vision screening procedure (children)
99173	Vision screening procedure (children)
99174	Vision screening procedure (children)
99177	Visual acuity screening

Depression screening - Procedure codesHCPCSCovered

G0444

Depression screening for adults

Depression and Obesity Screening procedure codesmixedCovered

96160
96161
96127
G0444
G0447
G0473
96156
96158
96159
97802

1–10 of 13

1/2

Immunization and vaccine administration codesmixedCovered

90460
90461
90471
90472
90473
90474
90620
90621
90623
90632

1–10 of 64

1/7

Preventive pediatric health care / well-child visit codesCPT|HCPCSCovered

99381
99382
99383
99384
99385
99391
99392
99393
99394
99395

1–10 of 13

1/2

Cervical cancer / HPV testing and cytology codesmixedCovered

87623
87624
87625
87626
G0476
88141
88142
88143
88147
88148

1–10 of 21

1/3

Sensory (hearing) screening codesCPT|HCPCSCovered

92551
92651
V5008
92552
92567
92587
92588
92558
92650

Alcohol & drug use assessment / counseling codesmixedCovered

99406
99407
99408
99409
G0442
G0443

General preventive procedure codes (partial list)mixedCovered

P3000	Procedure code listed under Commercial Preventive Care Services
P3001	Procedure code listed under Commercial Preventive Care Services
Q0091	Procedure code listed under Commercial Preventive Care Services
3015F	Procedure code listed under Commercial Preventive Care Services
G0101	Procedure code listed under Commercial Preventive Care Services
G0123	Procedure code listed under Commercial Preventive Care Services
G0124	Procedure code listed under Commercial Preventive Care Services
G0141	Procedure code listed under Commercial Preventive Care Services
G0143	Procedure code listed under Commercial Preventive Care Services
G0144	Procedure code listed under Commercial Preventive Care Services

1–10 of 13

1/2

Well Woman Exam Procedure CodesCPTCovered

99383	Well woman exam procedure code
99384	Well woman exam procedure code
99385	Well woman exam procedure code
99386	Well woman exam procedure code
99387	Well woman exam procedure code
99393	Well woman exam procedure code
99394	Well woman exam procedure code
99395	Well woman exam procedure code
99396	Well woman exam procedure code
99397	Well woman exam procedure code

1–10 of 20

1/2

Immunization Codes (selected)CPTCovered

90678	RSV immunization
90679	RSV immunization
90380	RSV immunization
90381	RSV immunization
90683	RSV immunization
90480	COVID-19 immunization administration
91318	COVID-19 vaccine product
91319	COVID-19 vaccine product
91320	COVID-19 vaccine product
91321	COVID-19 vaccine product

1–10 of 12

1/2

Mobile app and Breastfeeding Supplies CodesCPT/HCPCSCovered

A4267	Mobile application procedure code
A4268	Mobile application procedure code
A4269	Mobile application procedure code
J7299	Mobile application procedure code (requires modifier/diagnosis pairing)
99199	Mobile application procedure code
A9293	Mobile application procedure code
S9443	Breastfeeding supply code
E0602	Breastfeeding equipment
E0603	Breastfeeding equipment
E0604	Breastfeeding equipment

General preventive office visit CPTsCPTCovered

99202	Office/outpatient visit
99203	Office/outpatient visit
99204	Office/outpatient visit
99205	Office/outpatient visit
99211	Office/outpatient visit - established
99212	Office/outpatient visit - established
99213	Office/outpatient visit - established
99214	Office/outpatient visit - established
99215	Office/outpatient visit - established
99417	Prolonged service

1–10 of 11

1/2

Breastfeeding services and suppliesHCPCSCovered

S9443	Breastfeeding counseling/supplies (HCPCS)
E0602	Breast pump, standard
E0603	Breast pump, hospital-grade
E0604	Breastfeeding supplies

Breastfeeding supply HCPCSHCPCSCovered

A4281	Breastfeeding supplies
A4282	Breastfeeding supplies
A4283	Breastfeeding supplies
A4284	Breastfeeding supplies
A4285	Breastfeeding supplies
A4286	Breastfeeding supplies
A4288	Breastfeeding supplies
A9900	Miscellaneous DME supply

Hepatitis C screening CPTsCPTCovered

86803	HCV antibody test
87521	HCV RNA or NAT

Lung cancer screeningCPT | HCPCSCovered

71271	LDCT for lung cancer screening
G0296	LDCT lung cancer screening

Fall prevention / community-dwelling older adultsCPTCovered

97161	PT evaluation
97162	PT re-evaluation
97163	Occupational therapy evaluation
97164	Occupational therapy re-evaluation
97116	Gait training
97110	Therapeutic exercises
97150	Therapeutic procedure, group
97112	Neuromuscular reeducation
97530	Therapeutic activities

PrEP and related laboratory codes (selected)CPT | HCPCSCovered

81003	Urine dipstick
82565	HIV antigen/antibody testing
82575	HIV confirmatory testing
84460	Hepatitis B surface antigen
84702	HIV-1/2 antibody
86701	Syphilis test
86803	HCV antibody test
G0499	HIV screening (non-face-to-face)
G0432	HIV counseling
G0433	HIV counseling

Preventive medicine comprehensive visitsCPTCovered

99384	Initial comprehensive preventive visit 40-64
99385	Initial comprehensive preventive visit 18-39
99386	Initial comprehensive preventive visit 40-64
99394	Periodic comprehensive preventive visit 18-39
99395	Periodic comprehensive preventive visit 40-64
99396	Periodic comprehensive preventive visit 65+

Sexually transmitted infection and HIV screening codesCPTCovered

86701	Syphilis test
86703	HIV-1/2 antibody
87490	Chlamydia NAAT
87491	Gonorrhea NAAT
87590	Trichomonas or other STI test
87591	STI test
87810	Specific organism test
87850	Sexually transmitted infection test

Commercial Preventive Care Services - Preventive visit CPTsCPTCovered

99384	Preventive medicine visit
99385	Preventive medicine visit
99386	Preventive medicine visit
99394	Preventive medicine visit (established)
99395	Preventive medicine visit (established)
99396	Preventive medicine visit (established)

Preventive Medicine Counseling CPTsCPTCovered

99401	Preventive medicine counseling
99402	Preventive medicine counseling
99403	Preventive medicine counseling
99404	Preventive medicine counseling

Behavior Change Interventions CPTsCPTCovered

99406	Behavior change interventions
99407	Behavior change interventions

Tuberculosis testing & test reading / associated visit CPTsCPTCovered

86580	Tuberculosis testing (Mantoux)
99211	Office visit, low complexity (used in TB testing entries)
99212	Office visit
99213	Office visit

Sexually Transmitted Infection and HIV Screening CPTsCPTCovered

86701	Syphilis test
86703	HIV antibody test
87490	Chlamydia NAAT
87491	Gonorrhea NAAT (male)
87590	Chlamydia/Gonorrhea
87591	Chlamydia/Gonorrhea
87810	HIV antigen/antibody
87850	HIV test

Screening for Retinopathy CPTsCPTCovered

92227	Retinal imaging for diabetic retinopathy, unilateral or bilateral
92228	Remote imaging for retinopathy, unilateral or bilateral
92229	Remote imaging interpretation
92250	Fundus photography

A1C Testing CPTCPTCovered

83036

Hemoglobin A1c

INR (Prothrombin) Testing CPTsCPTCovered

85610	Prothrombin time
85611	Prothrombin time (repeat)

LDL Testing CPTsCPTCovered

83695	LDL cholesterol
83698	LDL cholesterol direct
83700	Lipoprotein, direct
83701	Lipoprotein
83704	Lipoprotein
83718	Lipoprotein
83719	Lipoprotein
83721	Lipoprotein
83722	Lipoprotein

Prostate Cancer Screening CPTsCPTCovered

84152	PSA test
84153	PSA test
84154	PSA test (free/total)

Prostate Cancer Screening CPT CodesCPTCovered

84152	CPT code listed for prostate cancer screening
84153	CPT code listed for prostate cancer screening
84154	CPT code listed for prostate cancer screening

Risk Assessment CPT CodesCPTCovered

96160	Risk assessment for sudden cardiac arrest and sudden cardiac death — administration code
96161	Risk assessment for sudden cardiac arrest and sudden cardiac death — interpretation/reporting code

Venipuncture CPT CodesCPTCovered

36415

Collection of venous blood by venipuncture

Diagnosis Codes referencedICD-10

Z00.00	Preventive visit
Z00.01	Preventive visit — with abnormal findings
Z12.5	Encounter for screening for malignant neoplasm of prostate
Z80.42	Family history of malignant neoplasm of prostate
Z13.6	Screening for cardiovascular disorders
Z82.42	Family history of sudden cardiac death

Colorectal cancer screening age range

Recommended age rangeAdults 45 to 75 years (USPSTF recommends); selective screening considered for ages 76–85

Scope of screeningIncludes FOBT/FIT, screening colonoscopy, sigmoidoscopy, sedation, pathology and related services

Guideline sourceUSPSTF Grade B recommendation (Release: May 18, 2021)

HIV screening age range

Recommended age rangeAdolescents and adults aged 15 to 65 years

Younger/older screeningScreen younger adolescents and older adults if at increased risk

Pediatric noteBright Futures: adolescence screening recommended at least once between ages 15 and 21 (confidentiality emphasized)

Osteoporosis screening age

Recommended age for routine screeningWomen 65 years and older (USPSTF recommends bone measurement testing)

Younger postmenopausal womenScreen postmenopausal women younger than 65 years who are at increased risk per clinical risk assessment

Procedure codes referencedBone density and related imaging codes listed (e.g., 77078, 77080, 77081)

Diabetes screening age range

Recommended age rangeAdults aged 35 to 70 years with overweight or obesity (USPSTF recommends screening)

Screening testsGlucose and HbA1c testing (procedure codes e.g., 82947, 82948, 82950, 83036)

Follow-up actionOffer or refer patients with prediabetes to effective preventive interventions

AAA screening age and risk

Recommended age and riskOne-time screening for men ages 65 to 75 years who have ever smoked (ultrasonography)

Procedure examplesUltrasound codes listed (e.g., 76775, 76700, 76705, 76770, 76706)

Guideline sourceUSPSTF recommendation (June 2014)

Obesity referral BMI threshold

BMI threshold for referralBody mass index (BMI) of 30.0 or higher — refer to intensive, multicomponent behavioral interventions

Action recommendedClinicians should offer or refer adults with BMI ≥30 to intensive multicomponent behavioral interventions

Guideline sourceUSPSTF recommendation (document references in Commercial Preventive Care Services)

BMI threshold for pediatric intervention

Pediatric BMI threshold>=95th percentile for age and sex (children/adolescents ≥6 years) — refer to comprehensive, intensive behavioral interventions

Age rangeChildren and adolescents 6 years or older

Payment noteProcedure codes for interventions listed and payable as preventive regardless of medical diagnosis in many cases

Lung cancer screening eligibility

Eligibility criteriaAdults aged 50 to 80 years with a 20+ pack-year smoking history who currently smoke or quit within the past 15 years (effective 03/09/2021)

Prior criteria notedPrevious USPSTF guidance used ages 55–80 with 30+ pack-years (document lists both original and updated criteria)

Screening interval and discontinuationAnnual low-dose CT recommended; discontinue screening after 15 years since quitting or if life expectancy/fitness for curative surgery is limited

Prior authorization requirement

Prior authorization requirementPlan authorization requirements must still be met for services that require prior authorization

In-network requirementPreventive services must be rendered by an in-network provider for 100% coverage; out-of-network coverage varies by plan

Documentation noteWhen preventive and non-preventive services occur during the same visit, documentation must support separate billing; modifier 33 may be used when applicable

Billing, Documentation & Provider Requirements

Prior Authorization

Prior authorization requirement

Plan authorization requirements must still be met for services that require prior authorization. Preventive services are covered at 100% when rendered by an in‑network provider per federal requirements; out‑of‑network preventive coverage varies by plan — check the member's Evidence of Coverage. When preventive and non‑preventive services occur on the same day, documentation must clearly support both services if both are billed. If minor additional work is performed, preventive services may be included in the medical office visit code; otherwise bill separate preventive codes with appropriate diagnosis/modifier pairing.

In‑network preventive services: 100% coverage when rendered by in‑network provider (check EOC for plan details).
Out‑of‑network preventive coverage varies by POS/PPO and plan; many POS/PPO plans do not cover preventive care out‑of‑network (except mammography per benefit booklet).
Plan authorization (prior authorization) rules still apply for services that require prior authorization.
When preventive and medical services co‑occur: document both services clearly; use modifier 33 where appropriate and only when ACA or regulation mandates preventive designation.

Billing Rule

Hepatitis B screening (pregnant women)

Hepatitis B screening for pregnant women at the first prenatal visit (CPT/HCPCS 87340, 87341) is payable as preventive when billed with any pregnancy or maternity diagnosis — no prior authorization required for preventive payment.

Procedure codes: 87340, 87341
Billing note: Payable as preventive with any pregnancy or maternity diagnosis.

Billing Rule

Preventive service procedure codes payable as preventive

Certain procedure codes and services listed in this policy are explicitly payable as preventive regardless of the associated medical diagnosis when submitted with the listed CPT/HCPCS and/or diagnosis combinations. Examples include screening mammography (77063, 77067), selected counseling/screening codes (G0444, G0446, G0473, G0447), many immunization and preventive visit codes, select lab and monitoring panels, and others enumerated in the policy. Providers should submit the listed CPTs with the corresponding preventive diagnosis codes or modifier(s) as specified to obtain preventive payment.

Examples of procedure codes flagged Payable as preventive regardless of medical diagnosis: 77063, 77067, G0444, G0446, G0473, G0447, 99384–99386, 99394–99396, and many immunization codes (90460–90759 series).
Follow the policy code listings for exact CPT/HCPCS and diagnosis pairings to ensure preventive payment.

Billing Rule

Mobile application billing rules

Mobile application-related procedure codes are payable as preventive when submitted per the policy. Specific billing rules and modifiers apply — review the code list and required diagnosis/modifier pairings. Note: if a provider prescribes an FDA‑approved/cleared contraceptive mobile medical app as medically indicated, the member may be responsible for payment.

Procedure codes: A4267, A4268, A4269, J7299, 99199, A9293
J7299 requires modifier 33 or specific pregnancy/contraceptive encounter diagnosis codes as listed.
If provider prescribes FDA‑cleared contraceptive mobile app (e.g., Natural Cycles, Clue Plus) as medically indicated, members will pay.

Documentation Required

Immunization documentation note

Immunizations and associated administration procedure codes are payable as preventive regardless of medical diagnosis when submitted with the listed immunization codes. Follow ACIP recommendations adopted by CDC when administering and documenting immunizations.

Examples of immunization procedure codes: 90460–90474, 90620–90759 and others listed in the immunization code series.
Documentation should reference ACIP/CDC guidance; immunizations are payable as preventive regardless of medical diagnosis code.

Billing Rule

Injection coverage note

Certain injections are payable as preventive regardless of medical diagnosis; federal plan members may have full coverage for specific injections. Review the injection code list and plan applicability.

Example injection codes listed as payable preventive: J0738, J0739, G0012, J0750.
Federal plan members: specified injections covered in full (check policy for effective dates and applicability).

Billing Rule

Preventive visit payable rule

Preventive medicine visit CPTs (99384–99386, 99394–99396) are payable as preventive regardless of medical diagnosis when submitted. When these codes are billed, they should be treated as preventive visits and reimbursed accordingly.

Procedure codes: 99384, 99385, 99386, 99394, 99395, 99396
When submitted: Payable as preventive regardless of medical diagnosis code.

Billing Rule

Pregnancy lab tests payable with contraceptive management diagnosis codes

Pregnancy laboratory tests (e.g., CPT 81025 and 84702) billed in combination with an encounter for contraceptive management are payable when submitted with the specified contraceptive management diagnosis codes (Z30.*). Ensure correct diagnosis coding when billing these pregnancy tests in the contraceptive management context.

Procedure codes: 81025, 84702
Allowed when billed with contraceptive management diagnosis codes such as Z30.011, Z30.012, Z30.013, Z30.014, Z30.017, Z30.018, Z30.019, Z30.02, Z30.09, Z30.2, Z30.9, Z30.430, Z30.431, Z30.432, Z30.433, Z30.46, Z30.49, Z30.8, Z98.51 (see policy for full list).

Billing Rule

PrEP documentation and billing note

Preexposure prophylaxis (PrEP) services have specific billing and documentation requirements. Laboratory and monitoring services for PrEP are payable as preventive when submitted with the listed procedure and diagnosis codes. Initiation and monitoring visits should be billed with appropriate visit codes and, where indicated, billed with modifier 33 and diagnosis codes Z11.3 or Z20.2 as specified.

PrEP laboratory procedure codes: (examples) 81003, 81025, 82565, 82575, 84460, 84702–84703, 86689, 86701–86706, 86780, 86592–86593, 86631–86632, 86803, G0499, 87110, 87270, 87320, 87340–87341, 87389–87391, 87517, 87534–87539, 87490–87492, 87521, 87590–87592, 87810, 87850, G0432, G0433, G0435
Initiation and monitoring visit codes include evaluation/management codes (99202–99205, 99211–99215), preventive visit codes (99417, G2211, G2212) and relevant labs/diagnostics.
Billing note: Billed with modifier 33 and the following: Z11.3, Z20.2 for certain PrEP initiation/monitoring services where indicated.
PrEP lab and monitoring services: Payable as preventive regardless of medical diagnosis when submitted with appropriate codes.

Documentation Required

Documentation: CPT + Dx pairing

When listed CPT codes are submitted with their corresponding preventive diagnosis codes or required modifiers (for example, modifier 33 when specified), services will be treated and paid as commercial preventive care. Always follow the CPT + Dx pairings in the policy to ensure preventive processing.

Use modifier 33 only where policy indicates and when ACA or regulation mandates preventive designation.
Examples: submit G0444 with preventive diagnosis to be payable regardless of medical diagnosis; submit PrEP initiation/monitoring with modifier 33 and Z11.3/Z20.2 as applicable.

Note

Contextual billing note

No explicit additional provider actions or step‑therapy rules are stated in these callouts beyond following the listed coding, modifier, and documentation requirements; providers should consult the full policy listings for service‑specific details and check member Evidence of Coverage for plan‑specific exceptions (grandfathered/PPACA‑exempt groups, federal plan differences).

Some services are labeled 'Payable as preventive regardless of medical diagnosis code' — follow the policy code lists.
No explicit prior‑authorization exceptions are stated here beyond the general prior authorization requirement; check plan rules for any required prior authorization.

Key Definitions & Screening Criteria

Preventive services criteria

Included guideline sourcesUSPSTF Grade A/B, Bright Futures (AAP), ACIP/CDC, HRSA, and applicable state/federal laws

Implementation timeframeHealth plans have one year to implement each new USPSTF recommendation

ScopeThese sources define preventive services covered with no member cost share when rendered in-network

Syphilis screening (pregnancy)

RecommendationUSPSTF recommends early screening for syphilis infection in all pregnant women

Risk-based screeningUSPSTF also recommends screening persons at increased risk for syphilis (Sept 2018; update Sept 2022)

TimingScreen early in pregnancy / at first prenatal visit as indicated

AAA screening (men 65–75, ever smoked)

RecommendationOne-time abdominal aortic aneurysm screening by ultrasonography for men ages 65–75 who have ever smoked

Procedure codesUltrasound procedure codes listed (e.g., 76775, 76700, 76705, 76770, 76706)

Guideline sourceUSPSTF recommendation (June 2014)

Obesity Screening (Adults)

Screening/referral thresholdAdults with BMI ≥30 should be referred to intensive, multicomponent behavioral interventions

ActionOffer or refer eligible adults to intensive behavioral interventions

Coding/paymentObesity screening procedure codes and diagnosis codes are listed and often payable as preventive regardless of medical diagnosis

Rh(D) Incompatibility Screening (Pregnancy)

Recommended testingRh(D) blood typing and antibody testing at first prenatal visit

Repeat testingRepeat Rh(D) antibody testing at 24–28 weeks for unsensitized Rh(D)-negative women unless biological father is Rh(D)-negative

Guideline sourceUSPSTF strong recommendation (February 2004)

Gestational diabetes screening timing

Timing for gestational diabetes screeningScreen asymptomatic pregnant persons at 24 weeks of gestation or after (preferably 24–28 weeks)

High-risk screeningScreen high-risk individuals earlier (e.g., at first prenatal visit) as clinically indicated

Guideline sourcesUSPSTF and HRSA/WPSI recommendations referenced

High BMI interventions for children

Pediatric intervention thresholdChildren and adolescents ≥6 years with BMI ≥95th percentile for age and sex should be provided or referred to comprehensive, intensive behavioral interventions

CodingProcedure codes for high-BMI interventions are listed (e.g., 96156, 96158, 96159, 97802–97804)

Reference dateRecommendation cited June 2024

LDCT lung cancer screening

Screening modality and intervalAnnual low-dose CT (LDCT) screening for eligible adults

Discontinuation criteriaDiscontinue screening if person has not smoked for 15 years or has limited life expectancy/ability to undergo curative lung surgery

PrEP

DefinitionPreexposure prophylaxis (PrEP) is antiretroviral therapy offered to persons at increased risk of HIV acquisition; clinicians should prescribe PrEP to persons at increased risk

Coverage elementsBaseline and monitoring laboratory tests and initiation/monitoring visits are covered; some items billed with modifier 33 and specific diagnosis codes for preventive payment

Guideline/source alignmentUSPSTF 'A' recommendation and CDC guidance (effective dates noted)

Prostate-specific antigen (PSA) test

Test definitionProstate-specific antigen (PSA) test: a blood test measuring PSA protein used for prostate cancer screening

Procedure codesCPT codes listed for PSA testing include 84152, 84153, 84154

Payment noteProstate cancer screening CPTs noted as payable as preventive regardless of medical diagnosis code (diagnosis examples listed)

OpenPayer

Commercial Preventive Care Services Coverage — Kaiser Foundation Health Plan of Washington

Covered Preventive Services & Criteria

Procedure, Diagnosis & Modifier Codes

Billing, Documentation & Provider Requirements

Guideline Sources & Policy Scope

Key Definitions & Screening Criteria