Coding Guidelines for Preventive Care Services Commercial ...

1 Coding Guidelines for Preventive care Services Commercial (Non-Medicare) Kaiser Permanente Plans Page 1 of 20 EXPLANATION: In accordance with the Patient Protection and Affordable care Act (commonly referred to as federal health care reform), Kaiser Foundation Health Plan of Washington is required to provide 100% coverage for Preventive care Services when Services are rendered by a provider in the member s plan network. Please check the member s benefit booklet for coverage details. Grandfathered and PPACA exempt groups are not subject to this requirement, but many of these groups have opted to cover Preventive Services with no cost share. This means that members will have no cost shares when Preventive Services are rendered by an in-network provider.

2 Non- Preventive Services received in conjunction with a Preventive service visit may be subject to member cost shares. Plan authorization requirements must still be met for Services that require prior authorization. Except for mammography, many Kaiser Foundation Health Plan of Washington Options, Inc. point-of -service (POS) and preferred provider organization (PPO) pl ans do not cover Preventive care out-of -network. Members should check their benefits booklet to confirm coverage on their specific plan. Out-of -network screening mammography is covered at the same benefit level as any other covered out-of -network service, unless stated otherwise in the benefit booklet.

3 If a non- Preventive service is performed during a Preventive care visit, applicable member cost shares apply. Preventive Services identified in these Guidelines are based on recommendations from: Items designated by the US Preventive Services Task Force as Grade A or Grade B Recommendations (Health plans have one year to implement each new recommendation) Items designated as Preventive by the Bright Futures program of the American Academy of Pediatrics State and Federal (HHS) laws that require certain additional Services be considered Preventive for certain populations APPLICABILITY: All non -Medicare, non-grandfathered Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc.

4 Plans. For Self-Funded plans, refer to the plan document. USING THE TABLES: The tables below include Coding details for: General principles and code sets referenced throughout the document (grey) Page 2 of 20 Commercial coverage for USPSTF requirements (green) Bright Futures requirements (blue) Women s Health Preventive Services requirements (beige) Table of ICD-10 pregnancy diagnosis codes (purple) There may be Services outside of those listed below that are covered as Preventive . This table includes Services that are mandated as Preventive coverage only. Additional Preventive Services may be covered. Members should contact Kaiser Permanente directly with questions about Preventive Services beyond what is included in this document.

5 *GENERAL: CPT Diagnosis codes 99201 - 99215 In certain circumstances as identified on the chart below, modifier 33 can be added to this code series to designate that the visit falls under an ACA Preventive care requirement. This modifier should only be used in circumstances where Preventive coverage is mandated by the ACA or other regulation and no other appropriate code set designates the service as Preventive . In cases where Preventive Services are provided on the same day as medical Services , those Services may be included in the medical office visit code (when minor additional work is performed) or separately billed using the appropriate Preventive Services code(s).

6 Documentation should clearly support both Services if both Services are billed. 99381 - 99397 , , , , , , , , , 99395 99397 , , , * Many Services referenced in the following tables state Included as part of visit for Preventive visits or problem-related visits. Those Coding rules are explained here in the General table. Commercial Preventive care Services Topic Procedure codes Diagnosis codes Comment Abdominal Aortic Aneurysm Screening: Men 76770 76775 76706 Men from ages 65-75 (ends on 76th birthday) Page 3 of 20 Commercial Preventive care Services Topic Procedure codes Diagnosis codes Comment (June 2014) Alcohol Misuse Screening and Counseling 99408 99409 G0442 G0443 Payable as Preventive regardless of diagnosis code.

7 Anemia, Iron Deficiency Anemia Screening: Pregnant Women 80055 85004 85014 85013 Payable as Preventive with pregnancy diagnosis- see pregnancy diagnosis code tables below Blood draw (36415) covered as Preventive when done with Preventive labs Aspirin for the Prevention of Cardiovascular Disease (Counseling) Included as part of visit for Preventive visits or problem-related visits* 99401 99404 (when the only service provided) Payable as Preventive regardless of diagnosis code. For a list of Preventive drugs, click here. Bacteriuria Screening: Pregnant Women 81007 (UA) 87086 87088 Payable as Preventive with pregnancy diagnosis- see pregnancy diagnosis code tables Blood Pressure Screening Included as part of visit for Preventive visits or problem-related visits* 99401 99404 (when the only N/A Page 4 of 20 Commercial Preventive care Services Topic Procedure codes Diagnosis codes Comment service provided) Risk Assessment, Genetic Counseling, and Genetic Testing for BRCA-Related Cancer in Women Included as part of visit for Preventive visits or problem-related visits* 99401 99404 (when the only service provided) 81211-81217 96040.

8 , Blood draw (36415) covered as Preventive when done with Preventive labs Breast Cancer Preventive Medication 99401-99404 (when the only service provided) N/A For a list of Preventive drugs, click here. Breast Cancer Screening Mammography 77057 77067 G0202 Payable as Preventive regardless of diagnosis code. Breastfeeding Counseling Included as part of visit for Preventive visits or problem-related visits* 99401 99404 (when the only service provided) Payable as Preventive regardless of diagnosis code. Page 5 of 20 Commercial Preventive care Services Topic Procedure codes Diagnosis codes Comment S9443 Cervical Cancer Screening, Pap Smear 88141-88143 88147-88148 88150-88155 88164-88165 88166 - 88167 88174- 88175 , , , , , , , Chlamydia screening : women (September 2014) 86631 86632 87110 87490 87491 87801 87270 87320 87492 87810 Covered with all diagnosis codes, except chlamydia diagnosis or when submitting code 87801 or 87810.

9 If submitting with code 87801 or 87810: , , , , , , , , , Blood draw (36415) covered as Preventive when done with Preventive labs Cholesterol Screening (Lipid Disorders Screening) 83719 80061 83718 83721 82465 84478 , , Blood draw (36415) covered as Preventive when done with Preventive labs Colorectal Cancer Screening Code Group 1: Cologuard: 81528 (effective 05/07/2017) Code Group 1: Code Group 1: Ages 50-75. G codes covered as Preventive regardless of dx Page 6 of 20 Commercial Preventive care Services Topic Procedure codes Diagnosis codes Comment Code Group 2: 82270 82274 45330 45331 45333 45338 45346 45378 45380 45381 45384 45385 45388 45300 45305 45308 45309 45315 45317 G0104-G0106 G0120-G0122 G0328 Code Group 3: 99152 99153 G0500 Code Group 2: , , , , , (for positive screening FOBT results leading to sigmoidoscopy or colonoscopy) Code Group 3: , , , , , Page 7 of 20 Commercial Preventive care Services Topic Procedure codes Diagnosis codes Comment Code Group 4.

10 Pre-procedure consultation: 99211-99205 99241-99245 & S0285 Code Group 4: Pre-procedure consultation must be billed with Modifier 33 and one of the following diagnoses: , , Prevention of Dental Caries in Preschool Children (Counseling) Included as part of visit for Preventive visits or problem-related visits* 99401 99404 (when the only service provided) N/A Preventing Dental Caries in Children from Birth through age 6 years (ends on 7th birthday) 99188 Does not have diagnosis code requirements for Preventive benefit to apply. Implemented May, 2015 Depression Screening in Adults Included as part of visit for Preventive visits or problem-related visits* 99401 99404 (when the only service provided) G0444 Payable as Preventive regardless of diagnosis code.