Kaiser Permanente Preventive Services Coverage Update

Preventive Services Coverage Criteria

General preventive coverage

Covered when ALL of the following apply:

ACA preventive coverage: Preventive services recommended by USPSTF Grade A/B, Bright Futures, ACIP/CDC, HRSA, state/federal laws, and Kaiser are covered with no member cost share when rendered in-network; grandfathered and PPACA‑exempt groups may be exceptions.

See member Evidence of Coverage; plan prior authorization requirements still apply.

Colorectal cancer screening

Covered when ALL of the following are met:

Target age group: Patient is an adult aged 45 to 75 years (USPSTF recommends selective screening for ages 76–85).45-75 years

Grade B recommendation; includes FOBT/FIT, screening colonoscopy, flexible sigmoidoscopy and related services; bill with listed colorectal screening procedure codes.

HIV and Osteoporosis screening

Covered when ANY of the following recommended screening criteria are met:

HIV screening: Screening per USPSTF for adolescents and adults aged 15 to 65 years; younger/older persons at increased risk should also be screened. Screening is payable as preventive regardless of medical diagnosis and with pregnancy-related diagnosis codes when applicable.15-65 years

Bright Futures: screen adolescents at least once between ages 15 and 21; bill using listed HIV screening procedure codes.

Osteoporosis screening: Bone mineral density (BMD) testing recommended by USPSTF for women 65 years and older and for younger postmenopausal women at increased risk determined by formal risk assessment.women >=65 years

Use listed osteoporosis procedure codes for preventive billing.

Newborn screening (phenylketonuria, congenital hypothyroidism) and vision

Covered when ALL of the following are satisfied:

Newborn metabolic and vision screening: Newborn screening for phenylketonuria and congenital hypothyroidism and newborn vision screening are covered as commercial preventive services in accordance with Bright Futures/HRSA Uniform Screening Panel recommendations and state newborn screening requirements.

Submit the designated preventive procedure codes (e.g., S3620, 83020/83021 and listed newborn screening codes) and newborn diagnosis codes (Z00.110/Z00.111) to receive preventive payment.

Syphilis and hepatitis B screening

Covered when ALL of the following are met:

Syphilis screening is covered for persons at increased risk and early screening is recommended for all pregnant women; submit the listed syphilis procedure codes (86592, 86593, 86780) and pregnancy/maternity diagnosis codes as applicable.

USPSTF: screen persons at increased risk; early pregnancy screening recommended; bill with pregnancy diagnosis codes for preventive payment.

Hepatitis B screening in pregnancy: Hepatitis B surface antigen testing is covered for pregnant women at their first prenatal visit; submit the listed HBV procedure codes (87340, 87341) with pregnancy/maternity diagnosis codes to be payable as preventive.first prenatal visit

USPSTF recommendation (July 2019); bill with pregnancy diagnosis codes.

Prediabetes and type 2 diabetes screening

Covered when ALL of the following are met:

Prediabetes / Type 2 diabetes screening: USPSTF recommends screening adults aged 35 to 70 years who have overweight or obesity; covered procedure codes include glucose and HbA1c tests (82947, 82948, 82950, 83036).age 35-70 with overweight/obesity

Refer patients with prediabetes to effective preventive interventions; bill with listed screening diagnosis codes.

AAA screening

Covered when ALL of the following are met:

AAA one-time screening: One-time abdominal aortic aneurysm screening by ultrasound is covered for men aged 65 to 75 years who have ever smoked; use the listed ultrasound CPT codes (e.g., 76775, 76700, 76705, 76770, 76706).men 65-75 who ever smoked

USPSTF June 2014 recommendation; bill with listed AAA screening procedure codes and appropriate diagnosis codes.

Depression and anxiety screening

Covered when screening is performed per USPSTF recommendation and billed with the listed preventive screening codes:

Depression and anxiety screening (adults): USPSTF recommends screening for depression and for anxiety disorders in adults (including pregnant and postpartum persons); use listed procedure codes (96127, 96160, 96161, G0444). G0444 is payable as preventive regardless of diagnosis when submitted appropriately.

Screening should be implemented with systems for follow-up and treatment; bill with listed preventive CPTs and diagnosis codes (Z13.31, Z13.39, Z00.121/Z00.129 as applicable).

Behavioral counseling / obesity interventions

Covered when ALL of the following are met:

Behavioral counseling for diet, physical activity and obesity: USPSTF recommends offering or referring adults with cardiovascular risk factors or BMI ≥30 to intensive behavioral counseling interventions; counseling and medical nutrition therapy procedure codes (97802-97804, G0473, G0447, 96156/58/59, S9470) are listed for preventive billing.BMI >= 30 for obesity interventions

Multiple CPT codes listed for nutrition therapy and behavioral counseling; payable as preventive when billed with the specified procedure codes.

Depression Screening (Children & Adolescents)

Covered when ALL of the following are met:

Depression screening (children & adolescents): USPSTF recommends screening for major depressive disorder and suicide risk in children and adolescents (≤18 years) without a diagnosed depressive disorder and without current symptoms; adolescent screening emphasis is ages 12–18. Use procedure codes 96160, 96161, 96127 and G0444 where applicable (G0444 payable as preventive regardless of diagnosis when submitted appropriately).age <=18 (adolescent focus 12-18)

Ensure systems for accurate diagnosis, treatment, and follow-up are in place.

Obesity Screening (Adults)

Covered when ALL of the following are met:

Obesity screening (adults): USPSTF recommends that clinicians offer or refer adults with BMI of 30 or higher to intensive, multicomponent behavioral interventions; bill using listed obesity screening and counseling procedure codes (G0447, G0473, 96156/58/59, 97802-97804, S9470).BMI >= 30

Payable as preventive regardless of diagnosis when billed with specified procedure codes and supporting documentation.

Rh(D) Incompatibility Screening (Pregnancy)

Covered when ALL of the following are met:

Rh(D) blood typing and antibody testing in pregnancy: USPSTF strongly recommends Rh(D) blood typing and antibody testing at the first prenatal visit for all pregnant women; repeat antibody testing for unsensitized Rh(D)-negative women at 24–28 weeks' gestation unless the biological father is known to be Rh(D)-negative. Procedure codes include 86900, 86850, 86901.first prenatal visit; repeat at 24-28 weeks if unsensitized

Bill with pregnancy/maternity diagnosis codes to be payable as preventive.

Pediatric/Newborn/Immunizations/STI/Cervical Cancer Preventive Services

Covered when ALL of the following are met and billed with the listed procedure codes:

Newborn metabolic and hemoglobinopathy screening: Bright Futures/HRSA recommended newborn screening panel (including sickle cell and other core disorders) and newborn hemoglobinopathy screening are covered; submit listed newborn screening procedure codes (e.g., 83020, 83021, 85660, S3850, and molecular panel codes) with diagnosis codes Z00.110/Z00.111 for preventive payment.as per state newborn screening programs

Follow state law and the Bright Futures Uniform Screening Panel guidance; omission of designated procedure code may affect preventive reimbursement.

Preventive pediatric health care: Preventive pediatric visits and Bright Futures–based age-appropriate services from newborn through 21 years are covered; submit preventive pediatric visit procedure codes (99381–99395, G0438/G0439) and applicable diagnosis codes.age-based schedule newborn to 21

If a child comes under care late or misses items, bring the schedule up to date at earliest opportunity.

Well-woman / preventive visits

Covered when ALL of the following are satisfied and billed with listed procedure codes or preventive visit CPTs:

Well-woman visits: Well-woman and related preventive visits are covered to deliver and coordinate recommended preventive services across the lifespan; HRSA/WPSI recommends at least one preventive visit per year beginning in adolescence. Submit listed well-woman CPTs (99383–99387, 99393–99397) or other specified preventive visit CPTs and applicable diagnosis codes for preventive payment.

Services may be provided in a single visit or series of visits depending on needs; many well-woman codes are payable as preventive regardless of medical diagnosis code.

High BMI interventions

Covered when ALL of the following are met:

High BMI interventions (children/adolescents): USPSTF recommends referral of children and adolescents aged ≥6 years with BMI ≥95th percentile for age and sex to comprehensive, intensive behavioral interventions; listed procedure codes for counseling and interventions apply and are payable as preventive.BMI ≥95th percentile for age and sex

June 2024 USPSTF recommendation; bill with the listed preventive procedure codes.

Pregnancy screening (GDM, hypertensive disorders)

Covered when ALL of the following are met:

Gestational diabetes screening: Screening for gestational diabetes is covered in pregnancy after 24 weeks (preferably 24–28 weeks) per USPSTF and HRSA/WPSI guidance; submit gestational diabetes screening procedure codes (82947–82952, 83036) with pregnancy/maternity diagnosis codes for preventive payment.>=24 weeks gestation

Payable as preventive with any pregnancy or maternity diagnosis.

Hypertensive disorders of pregnancy screening: Blood pressure measurement and screening for hypertensive disorders throughout pregnancy are covered; bill with pregnancy diagnosis codes as preventive when appropriate.ongoing throughout pregnancy

USPSTF Release Sept 2023 (formerly preeclampsia screening).

Immunizations

Covered when ALL of the following are met and billed with listed procedure codes:

Routine immunizations: ACIP/CDC-recommended immunizations (multiple vaccine product and administration CPT/HCPCS codes listed) are covered as preventive services and are payable as preventive regardless of medical diagnosis when billed with the listed procedure codes.ACIP schedule

Includes HepB, Rotavirus, DTaP, Hib, Pneumococcal, Polio, Influenza, MMR, Varicella, HepA, Meningococcal, HPV, Zoster, RSV, COVID-19, Mpox, BCG and others; use listed administration codes (90460–90474) where required.

Contraceptive services

Covered when ALL of the following are met:

Contraceptive methods and counseling: Contraceptive insertion/removal procedures, counseling, and related supplies are covered when billed with specified procedure codes and appropriate diagnosis linkage (Z30.* and other codes); some supplies and mobile app prescriptions have special reimbursement notes.

Use specified procedure and diagnosis codes (see contraception code groups); FDA-approved contraceptive mobile apps if prescribed may require member out-of-pocket payment with possible reimbursement submission.

Breastfeeding support

Covered when ALL of the following are met and billed with listed procedure/HCPCS codes:

Breastfeeding services and supplies: Comprehensive lactation support services (counseling, education, equipment, supplies) are covered as preventive services; submit the enumerated procedure and supply codes (e.g., 99393–99396, S9443, E0602, A4281–A4288) with applicable diagnosis codes to be payable as preventive.

HRSA/WPSI and USPSTF recommendations cited; many breastfeeding supply codes are payable as preventive regardless of diagnosis.

Screening & counseling (IPV, Hep C)

Covered when ALL of the following are met:

Interpersonal and domestic violence screening (IPV): Clinicians should screen women of reproductive age for intimate partner violence during the annual well-woman visit and provide or refer women who screen positive to ongoing support services; include IPV screening as part of preventive visit billing.

Bill the annual well-woman visit using listed preventive visit CPTs.

Hepatitis C screening: USPSTF-recommended HCV screening is covered with listed HCV CPTs (86803, 87521) for adults age 18–79 and persons at high risk; submit listed diagnosis and procedure codes to be payable as preventive.Adults 18-79 or high-risk individuals

One-time screening for birth cohort or high-risk populations as per USPSTF guidance.

Covered preventive services per topic

Covered when ALL of the following topic-specific criteria are met (per referenced guidance):

Breastfeeding services and supplies (topic): Breastfeeding services and supplies enumerated with procedure/HCPCS codes are included as commercial preventive services; certain codes (S9443, E0602, E0603, A4287) are payable as preventive regardless of medical diagnosis code.

See breastfeeding code group for specific codes and diagnosis linkages.

Hepatitis C screening (topic): HCV screening is covered per USPSTF for adults age 18–79 and persons at high risk; CPTs 86803 and 87521 are included as preventive test codes.Adults 18-79 or high-risk individuals

Refer to coding group for listed HCV CPTs.

Lung cancer screening (topic): Annual low-dose CT screening is covered for adults meeting USPSTF criteria (age and smoking history thresholds as listed); CPT/HCPCS codes include 71271 and G0296.Age 50-80 and >=20 pack-year history per USPSTF

Covered preventive services (code-linked)

Covered when billed with the listed CPT/diagnosis code pairings as examples below:

Retinopathy and diabetes testing examples: Retinopathy screening (CPT 92227–92250) when billed with listed diabetes diagnosis codes; A1C testing (CPT 83036) with listed diabetes or screening diagnosis codes; INR testing (CPT 85610–85611) for liver disease/bleeding disorders with listed diagnosis codes; LDL testing (CPTs 83695–83721) with cardiac-related diagnosis codes.

These are code-linked examples from the document; providers must submit the listed CPT(s) with appropriate supporting ICD-10 diagnosis codes for preventive payment.

Prostate cancer screening example: PSA testing CPTs 84152–84154 listed with screening diagnosis codes (Z00.00, Z00.01, Z12.5, Z80.42) for preventive screening of prostate cancer.

Purpose: identify high-risk localized prostate cancer amenable to curative treatment; bill with listed screening diagnosis codes.

Listed preventive services and associated codes/comments

Prostate cancer screening (PSA): PSA testing CPTs 84152–84154 listed with diagnostic codes Z00.00, Z00.01, Z12.5, Z80.42; submit these CPT and diagnosis codes when performing screening to align with preventive coverage expectations.

From coding listings in the preventive services document (chunk 109).

Risk assessment for sudden cardiac arrest/death: CPTs 96160 and 96161 listed for risk assessment with diagnosis codes Z13.6 and Z82.42; Bright Futures adds assessment timing from ages 11 to 21 years.ages 11-21

Use listed CPTs and diagnosis codes when performing preventive risk assessment in the specified age range.

Venipuncture for preventive services: Collection of venous blood (CPT 36415) is the applicable procedure for preventive services that require venipuncture; submit CPT 36415 with the preventive service CPTs and diagnosis codes when indicated.

Applicable to any covered preventive service requiring venipuncture.

Grandfathered and PPACA‑exempt groups are not subject to the Affordable Care Act preventive coverage mandate and therefore may not automatically receive zero cost‑share for USPSTF/HRSA/ACIP‑recommended preventive services. Many of these groups have elected to cover preventive services with no member cost share, but coverage and member financial responsibility for members in these groups depend on the plan's Evidence of Coverage. Plan authorization requirements still apply for services that require prior authorization, and non‑preventive services provided during a preventive visit may be subject to member cost share.

The USPSTF found the evidence to be insufficient to assess the balance of benefits and harms of routine screening for iron deficiency anemia in pregnant women to prevent adverse maternal and birth outcomes (USPSTF statement cited; September 2015).

Screening recommendations in this policy apply to asymptomatic individuals without a diagnosed disorder and who are not showing recognized signs or symptoms of the condition being screened for. For example, USPSTF depression screening recommendations apply to children and adolescents who do not have a diagnosed depressive disorder and who are not currently symptomatic; Bright Futures supports behavioral/social/emotional screening in preventive pediatric care.

Mobile contraceptive applications are noted in the policy. Kaiser identifies FDA‑approved/cleared contraceptive mobile apps (Natural Cycles and Clue Plus). If a provider prescribes an FDA‑approved/cleared contraceptive mobile application as medically indicated, the member will pay out of pocket at point of care and may submit for reimbursement per plan rules (procedure codes A9293 and 99199 referenced).

Lung cancer LDCT screening follows USPSTF criteria (annual LDCT for adults aged 50–80 with ≥20 pack‑year history who currently smoke or quit within the past 15 years). Screening should be discontinued once an individual has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to undergo curative lung surgery.

Within the provided excerpt there are no additional explicit exclusions listed for preventive services beyond plan‑specific exceptions (e.g., grandfathered/PPACA‑exempt groups noted elsewhere).

No explicit exclusions are listed in the cited chunks that enumerate procedure and diagnosis codes; the excerpt focuses on covered preventive services and associated CPT/ICD‑10 codes.

When non‑preventive services are provided in conjunction with a preventive visit they may not be payable as preventive services and are subject to the member's applicable cost share. Providers should bill preventive procedure codes and appropriate diagnosis codes for preventive items; separate non‑preventive services should be coded and billed according to usual benefit rules and may incur member cost share.

Cervical cytology screening guidance in this policy follows HRSA/WPSI and USPSTF recommendations: for average‑risk women, cervical cytology (Pap test) alone should not be performed more frequently than once every 3 years. Age‑based intervals apply (e.g., 21–29: cytology every 3 years; 30–65: cytology alone every 3 years or hrHPV alone every 5 years or cotesting every 5 years).

There are no explicit 'not medically necessary' (NMN) denial statements in these chunks. The document instead describes clinical stopping or discontinuation criteria for lung cancer screening (for example, discontinuation after 15 years smoke‑free or if life expectancy/ability to undergo curative surgery is substantially limited), which are clinical stopping rules rather than NMN exclusions.

Not specified in the provided excerpt.

No explicit 'not medically necessary' determination language appears in the referenced chunks; the content lists covered preventive services, CPTs, and diagnosis codes without NMN statements.

Procedure and Diagnosis Codes

General / Visit and Mammography CodesCPT

99202-99215	Office/outpatient visit codes (preventive/general)
99417	Prolonged office/other outpatient service
G2212	Visit complexity inherent to evaluation and management services
97802-97804	Medical nutrition therapy
99241-99245	Office consultation codes (99242-99245 included)

Mammography follow-up and pathologyCPT

77063	Screening digital breast tomosynthesis; unilateral or bilateral
77067	Screening mammography, bilateral
77065	Diagnostic bilateral mammography
77066	Diagnostic unilateral mammography
88304	Surgical pathology, gross and microscopic; level IV
88305	Surgical pathology, gross and microscopic; level V

STI screening CPT/NAAT codesCPTCovered

87490	Chlamydia trachomatis NAAT, direct probe or amplified probe technique
87491	Neisseria gonorrhoeae NAAT
87590-87592	Trichomonas and other pathogen NAATs (87590-87592 series)

Colorectal cancer screening codesCPTCovered

44388-44394	Lower intestinal endoscopy and related procedures
45300-45391	Colonoscopy and sigmoidoscopy procedure codes (selected screening codes)
74261-74263	Radiologic colon imaging
81528	Stool DNA test for colorectal cancer screening
82270	Fecal occult blood test, qualitative

HIV and Osteoporosis screening codesCPTCovered

G0432-G0475	HIV screening related prevention/assessment codes (G0432, G0433, G0435, G0475 referenced)
77078-77085	Bone density testing (DXA) codes for osteoporosis screening

Additional screening and counseling codesCPTCovered

99401-99404	Preventive counseling (various topics)
99408-99409	Substance abuse screening and counseling
G0442-G0443	Brief counseling for alcohol misuse
96160-96161	BHS/psychosocial and risk assessments
G0444	Depression screening instrument administration and interpretation

Newborn & Syphilis screening codesCPTCovered

84030-84035	Newborn metabolic screening panels (e.g., PKU)
86592-86593	Syphilis non-treponemal and treponemal tests (included)
86780	Treponema pallidum antibody test (specific)
S3620	Newborn screening panel codes
83020-83021	Newborn hemoglobin/related tests

Diabetes screening procedure codesCPTCovered

82947-82950	Glucose testing codes
83036	Hemoglobin A1c

Pediatric vision screening CPT codesCPTCovered

99172-99177

Pediatric vision screening codes

AAA screening ultrasound CPT codesCPTCovered

76700-76775

Abdominal ultrasound codes including screening for AAA

BRCA screening and genetic counseling codesCPTCovered

99385-99397	Preventive medicine visits (initial & periodic) including well-woman and BRCA risk assessment
81162-81165	BRCA1/BRCA2 genetic testing panels and related molecular codes
81212,81215-81217	Targeted BRCA/other hereditary cancer testing codes

Behavioral and mental health preventive service codesCPTCovered

96127,96160-96161

Brief depression/screening and psychological testing codes

Obesity screening and counseling codesCPTCovered

G0447,G0473	Intensive behavioral therapy for obesity
97802-97804	Medical nutrition therapy services
96156,96158-96159	Behavioral counseling/intervention codes

Hepatitis B screening in pregnancyCPTCovered

87340-87341

Hepatitis B surface antigen testing for pregnant women

Major Depressive Disorder/Depression Screening codesCPTCovered

96127,96160-96161,G0444

Depression and suicide risk screening administrative codes

Obesity Screening Codes (expanded)CPTCovered

97802-97804	Medical nutrition therapy (included)
S9470	Obesity-related counseling/supplies

Rh(D) Incompatibility Screening codesCPTCovered

86900,86901,86850

Rh(D) and antibody testing

Preventive Pediatric Health Care & Newborn ScreeningCPTCovered

99381-99461,G0438-G0439	Preventive pediatric visits and newborn care codes
83020-83021,84030-84035	Newborn screening metabolic/hemoglobin panels

Immunizations and administration codesCPTCovered

90460-90474,90620-90759	Immunization administration and vaccine product codes (selected series)
G0008-G0010	Administration codes for vaccines

Lead Screening codesCPTCovered

83655, 85013-85018

Lead screening and hematocrit/hemoglobin testing codes

STI and Cervical Cancer Screening/Cytology/HPV codesCPTCovered

87623-87626, G0476	HPV testing codes
88141-88155, 88164-88167	Cytology/Pap test codes
86701-86703, 86780	HIV/syphilis/other serologic testing codes (86780 included)
87490-87492, 87510-87535, 87590-87592, 87801-87850	NAAT and culture codes for STI testing
86592-86593	Syphilis serology tests (non-treponemal/treponemal) (included)

Well Woman Exam codesCPTCovered

99383-99397, S0610-S0613	Well-woman preventive visit series and related codes
G0101,G0123-G0148	Cervical cancer screening related (Medicare/alternative) codes

Preventive visit CPTsCPTCovered

99202-99215, 99417, G2212	Office visit and related preventive visit CPTs
99241-99245	Consultation codes (included)

Immunization CPT/HCPCS codesmixedCovered

90611,90622,90632-90636,90644-90651,90655-90674,90680-90689,90694-90699	Selected vaccine product HCPCS/CPT codes
Q2033-Q2038,Q2035-Q2038	Vaccine product HCPCS codes

High BMI interventions codesCPTCovered

96156,96158-96159,97802-97804

High BMI counseling and nutrition therapy codes

Breastfeeding services and suppliesmixedCovered

99393-99396,99401-99404	Preventive & counseling visits related to breastfeeding
S9443,E0602-E0604	Breast pump supply/service HCPCS
A4281-A4286,A4288,A9900	Breastfeeding supplies HCPCS

Contraceptive management / pregnancy testing codesCPTCovered

58340,58565,58600,58661,58670-58671	Contraceptive procedural codes
99202-99215	Encounter codes used with pregnancy testing/contraceptive management

Hepatitis C screening codesCPTCovered

86803,87521

HCV antibody and RNA testing codes

Lung Cancer Screening codesCPTCovered

71271, 71250

Low-dose CT lung screening and related CT codes (examples)

PrEP and injection-related codesmixedCovered

J0738,J0739,J0799,G0012	Injectable PrEP/administration codes
96372	Therapeutic injection code

PrEP lab services and STI/HIV screening codesCPTCovered

81003,81025	Urine pregnancy and urine dipstick/UA
82565,82575,84460,84702-84703	HIV/HBV/HCV and related serology
86631-86632,86701-86703	HIV antigen/antibody and other serologies
86780	Treponema pallidum antibody test (included for PrEP labs)
86592-86593	Syphilis screening tests (included for PrEP labs)

Retinopathy screening CPT codesCPTCovered

92227-92250

Retinal imaging and fundus photography codes for diabetes retinopathy screening

Preventive Medicine Counseling codesCPTCovered

99401-99404,99411-99412

Preventive counseling and education codes

Pediatric fluoride varnish codesCPTCovered

99188,99189

Fluoride varnish application for children (example CPTs)

A1C TestingCPTCovered

83036

Hemoglobin A1c testing (covered)

INR (Prothrombin) TestingCPTCovered

85610-85611

Prothrombin time (PT/INR) testing codes

LDL Testing CPT codesCPTCovered

83695,83698,83700,83704,83718,83719,83721,83722

Lipid panel and LDL related CPT codes

Prostate Cancer Screening CPT codesCPTCovered

84152-84154	PSA testing CPT codes for prostate cancer screening
G0101	Cervical/Cancer screening analog (example)

Selected diagnosis codes (examples)ICD-10

Z00.00	General adult medical examination without abnormal findings
Z00.121	Newborn/infant exam
Z11.3	Encounter for screening for infections with a predominantly sexual mode of transmission
Z11.4	Encounter for screening for HIV

GENERAL diagnosis codes (partial list)ICD-10

Z12.10	Encounter for screening for malignant neoplasm of colon
Z12.4	Encounter for screening for malignant neoplasm of cervix
Z13.1	Encounter for screening for diabetes mellitus
Z13.6	Encounter for screening for cardiovascular disorders

Venipuncture CPTCPTCovered

36415

Collection of venous blood by venipuncture

Billing, Prior Authorization, and Documentation Guidance

Billing Rule

Preventive Visit Codes Payable

Preventive visit codes (e.g., 99202–99215, 99417, G2212 and designated preventive CPT/HCPCS such as G0444, G0446, G0472, G0473, G0447, 99383–99397, well-woman and prenatal visit codes) may be billed as preventive when submitted per guidance. When applicable, use modifier 33 to designate ACA-mandated preventive services only when no other preventive code applies. Non-preventive services provided the same day may be billed separately only if documentation clearly supports both services.

Preventive visit series: 99202–99215, 99417, G2212
Use modifier 33 only where ACA/preventive regulation applies and no other preventive code exists
If both preventive and problem-focused services billed same day, document distinct services

Billing Rule

Preventive Injection / PrEP Medication Codes

Certain injections and PrEP-related medications and administration codes are payable as preventive when billed per the listed preventive guidance. Examples include J0738, J0739, G0012, J0750–J0752, J0799 and associated administration (e.g., 96372) and venipuncture codes (36415, 36416). For PrEP initiation/monitoring, bill appropriate E/M or preventive visit codes (99202–99215, G2211/G2212) with the listed diagnosis codes and modifier 33 when applicable.

Policy Background and Guideline Sources

This document compiles preventive services identified by authoritative sources — including the USPSTF (Grade A/B recommendations), Bright Futures, ACIP/CDC, HRSA, applicable state and federal laws, and internal Kaiser adoption — to define covered preventive services and the related billing/coding and coverage guidance for commercial plans.

Definitions and Key Terms

Preventive services — Services designated by USPSTF Grade A/B, Bright Futures, ACIP, HRSA, or law and adopted by Kaiser as preventive

DefinitionServices designated by USPSTF Grade A/B, Bright Futures, ACIP, HRSA, or law and adopted by Kaiser as preventive

Included examplesScreening tests, immunizations, behavioral counseling, and other services cited from USPSTF/Bright Futures/ACIP/HRSA

Coverage implicationWhen rendered in-network these preventive services are covered with no member cost share under ACA (subject to plan EOC and exceptions)

Bright Futures Uniform Screening Panel — Newborn screening program recommendation for core disorders

Program recommendationBright Futures / HRSA recommends that newborn screening programs include a Uniform Screening Panel for core disorders (35 core, 26 secondary)

Covered tests

Document Revision History

2026-04-03revisionLatest

Policy updated and last revised on April 3, 2026; multiple sections and code lists reviewed and confirmed (document shows 'Last Revised: April 3, 2026').

2021-03-09guideline_update_reference

USPSTF updated lung cancer screening recommendation effective March 9, 2021, reflected in screening age and pack-year thresholds within the policy.

2019-01-01federal_notice_reference

OpenPayer

Commercial Preventive Care Services (screening and counseling)

Preventive Services Coverage Criteria

Procedure and Diagnosis Codes

Billing, Prior Authorization, and Documentation Guidance

Policy Background and Guideline Sources

Definitions and Key Terms

Document Revision History