EmblemHealth Preventive Care/Screening Services Exempt ...

1 Medical Management Page 1 Adapted Jan 2021 EmblemHealth Preventive Care/Screening Services Exempt from Cost-Share The Affordable care Act (ACA) requires non-grandfathered health plans in the individual and group markets to cover certain Preventive / screening care Services received from in-network providers, in full, without member cost-sharing ( , without co-pay, deductible and/or co-insurance). In general, eligible Services include Preventive / screening care Services which have received an A or B rating from the United States Preventive Services Task Force (USPSTF) or have been set forth in comprehensive guidelines supported by the Health Resources and Services Administration (HRSA), as well as immunizations recommended by the Advisory Committee on Immunization Practices (ACIP) and the American Academy of Pediatrics Bright Futures guidelines. For additional information about these guidelines and recommendation, please click on the link(s) below: Instructions to Providers for Coding Claims for ACA Mandated Preventive care Services : In order to help EmblemHealth properly identify and accurately process claims for ACA-mandated Preventive / screening care Services , providers are asked to follow the coding guidelines and instructions below when submitting claims for these Services to the following EmblemHealth companies: Group Health Incorporated ( GHI ), Health Insurance Plan of Greater New York ( HIP ) and HIP Insurance Company of New York ( HIPIC ).

2 I) Annual Preventive care Medical Evaluation A. Preventive Medicine Visits should be reported with the appropriate patient age and gender specific procedure code from the 99381 through 99397 AMA CPT Code range. B. The associated Preventive / screening ICD-10 diagnosis code ( , , ) should be entered into the first claim diagnosis field. II) Preventive / screening Colonoscopy A. Services provided by the in-network endoscopist, anesthesiologist and pathologist associated with an in-network Preventive / screening colonoscopy are eligible for coverage without member cost-sharing. Medical Management Page 2 Adapted Jan 2021 B. With the understanding that a Preventive / screening colonoscopy may become diagnostic or therapeutic due to unforeseen findings, the AMA CPT Code that most accurately represents the procedure performed should be reported. C. The appropriate Preventive / screening ICD-10 diagnosis code ( , ) should be entered into the first claim diagnosis field.

3 D. Anesthesia Services should be reported with any specific findings entered into the first claim diagnosis field. The second claim diagnosis code should be reported with the appropriate Preventive / screening ICD diagnosis code ( , ). CPT code 00812 MUST be used if the screening colonoscopy becomes a diagnostic colonoscopy and/or if the screening colonoscopy is stopped due to poor preparation and a sigmoidoscopy is done. While modifier 33 may be reported along with the anesthesia CPT code, it is not used in making Preventive care benefit determinations; EmblemHealth considers the procedure and diagnosis codes when determining whether Preventive care benefits apply. Pathology Services should be reported with the appropriate screening ICD diagnosis code ( , ) entered into the first claim diagnosis field. III) All Other Preventive / screening Services ( , screening Mammography, Lipid Profile) A.

4 Eligible Preventive screening Services should be reported with the appropriate screening ICD diagnosis code ( , , , and ) and entered into the first claim diagnosis field. EmblemHealth Preventive Care/Screening Services Table: Important Notes ACA-mandated Preventive Care/Screening Services are Exempt from cost-sharing ONLY when performed within the health plan network under HMO. Coverage is subject to all terms, conditions, limitations and exclusions of the members EmblemHealth plan. This table represents criteria established by Federal and State agencies to determine when Services are considered Preventive . Any Services listed below rendered outside of those defined parameters may be subject to member cost share. Sections Click on the appropriate link to view the list of Preventive Services . General Preventive Screenings and Counseling Specific Screenings Immunizations Medical Management Page 3 Adapted Jan 2021 Preventive Service Procedure Code ICD-10 Diagnosis Codes Guidelines Comment Preventive screening Examination and Counseling Services 99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397 All Frequency: One procedure code/member/year Ages: All 99391, 99392 All Frequency: (see note) Well Child Visits: 11 well baby visits from birth to 23 months 2 well baby visits from age of 2 to 3 Ages: 0-23 months 96160, 96161 All Frequency: One procedure code/member/year Ages: All 99401, 99402, 99403, 99404 All Frequency: One procedure code/member/year Ages: All G0513, G0514 All Frequency: One procedure code/member/year Ages.

5 All Preventive Service Procedure Code ICD-10 Diagnosis Codes Guidelines Comment Abdominal Aortic Aneurysm (AAA) screening 76706 , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Frequency: 1x/lifetime Ages: 65-75 years Gender: M Medical Management Page 4 Adapted Jan 2021 Alcohol screening 99408, 99409, G0396, G0397, G0442, G0443 Frequency: 1x/year Ages: All Gender: M/F Autism, Psychosocial/Behavioral and Developmental screening 96110, 96127 , , , Frequency: 1x/year Ages: 0 21 years Gender: M/F Anemia (General) 85025 , , , , , , , , , Frequency: 1 x/year Ages: All Gender: M/F Breast cancer Genetic Counseling 96040 , , , , Frequency: 1/per lifetime Ages: All Gender: M/F Breast cancer , Genetic Testing (BRCA) 81162, 81163, 81164, 81165, 81166, 81167, 81212, 81215, 81216, 81217 , , , , , Frequency: 1/per lifetime Ages: All Gender: M/F *Prior Authorization for BRCA Testing: For most benefit plans, prior authorization requirements apply to BRCA lab screening .

6 Breast Feeding/Lactation Support 99501, 99502, S9443 All Frequency: Unlimited Ages: All Gender: F Breast Pumps E0602, E0603, E0604 All Frequency: 1 x/year Ages: All Gender: F Breast Pump Supplies A4281, A4282, A4283, A4284, A4285, A4286 All Frequency: 1 x/year Ages: All Gender: F Breast Supplemental screening and Diagnostic Imaging 76641, 76642, 77046, 77047, 77048, 77049 None Frequency: 1 x/year Ages: All Gender: F Medical Management Page 5 Adapted Jan 2021 Breast Tomosynthesis 77061, 77062, 77063, G0279 None Frequency: 1 x/year Ages: 35 years and over Gender: F Chlamydia screening 86631, 86632, 87110, 87140, 87270, 87320, 87490, 87491, 87492, 87800, 87801, 87810 All Frequency: 4x/year Ages: All Gender: F Colon cancer screening (Anesthesia and Ancillary Services ) 00812 All Frequency: Once every 5 years Ages: 45-75 years Gender: M/F Colon cancer screening 44388, 44389, 44391, 44392, 44394, 44401, 45300, 45303, 45305, 45308, 45309, 45315, 45317, 45320, 45330, 45331, 45333, 45334, 45335, 45338, 45346, 45378, 45380, 45381, 45382, 45384, 45385, 45388, 74263 , , , , , , , Frequency: Once every 5 years Ages: 45 75 years Gender: M/F screening colonoscopy pre- procedure consultations 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215 Frequency: Once every 5 years Ages: 45 75 years Gender: M/F Colon cancer screening (Pathology) 88305 , , , , , , , Frequency: once every 5 years Ages: 45 75 years Gender: M/F Medical Management Page 6 Adapted Jan 2021 Colon and colorectal cancer screening (Stool For Occult Blood Lab Test) 82270, 82274 , , , , , , , Frequency.

7 Once every 5 years Ages: 45 75 years Gender: M/F colorectal cancer screening (Cologuard Lab Test) 81528 , , , Frequency: once every 3 years Ages: 45 85 years Gender: M/F Contraceptive Counseling 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99281, 99282, 99283, 99284, 99285 , , , , , , , , , , , , , , , , , , , , , Frequency: Unlimited Ages: All Gender: F Contraceptive Methods A4261, A4266 All Frequency: 4X/year Ages: All Gender: F A4264 All Frequency: 1X/year Ages: All Gender: F J7296, J7297, J7298, J7300, J7301, J7306, J7307, S4981, S4989 , , , , , , , , , , , Frequency: 1X/year Ages: All Gender: F J7303- deleted effective 9/30/2021 J7304 , , , , Frequency: 12X/year Ages: All Gender: F J7306, J7307 Frequency: 1X/year Ages: All Gender: F Medical Management Page 7 Adapted Jan 2021 Contraceptive Methods (cont.)

8 J1050 , Frequency: 4x/year Ages: All Gender: F S4993 Frequency: 12X/year Ages: All Gender: F 11976, 11980, 11981, 11982, 11983 , Frequency: 1X/year Ages: All Gender: F 58300, 58301 , , , , , Frequency: 1X/year Ages: All Gender: F 58562 , , , , , Frequency: 1X/year Ages: All Gender: F Creatinine (HIV PrEP) 82565, 82575 , , , , , , , , Frequency: 3X/year Ages: All Gender: M/F Dental Caries Prevention (Oral Fluoride Varnish) 99188 All Frequency: 2x/year Ages: 0 5 years Gender: M/F Pediatrician(s) or PCP providers only Depression screening G0444, 96127 , Frequency: 1x/year Ages: 12 years and over Gender: M/F Developmental screening 96110, G0451 , , Frequency: 1x/year Ages: up to age 18 Gender: M/F Medical Management Page 8 Adapted Jan 2021 Diabetes screening 82947, 82948, 82950, 82951, 82952, 83036 , , , Frequency: 1x/year Ages: All Gender: M/F Diabetes screening : Gestational 82947, 82948, 82950, 82951, 82952, 83036 , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Frequency: 2x/year Ages: All Gender.

9 F Dietary Counseling (Individuals Who are Overweight or Obese and Have Additional Cardiovascular Risk Factors) 97802, 97803, 97804, S9470 , , , , , , , , , , , , , , , , , I10, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , Frequency: 4 x/year Ages: All Gender: M/F Medical Management Page 9 Adapted Jan 2021 Fall Prevention 1100F, 1101F, 3288F (Note: No additional reimbursement is made for Measurement codes) , , , Frequency: Unlimited Age Band: 65+ Gender: M/F Folic Acid Daily Supplementation for Women planning for pregnancy J0640 All Frequency: 1x/day Ages: All Gender: F Gonorrhea screening 87590, 87591, 87592, 87850 All Frequency: 4x/year Ages: All Gender: M/F Gynecological Exam 99384, 99385, 99386, 99387, 99394, 99395, 99396, 99397 , Frequency: 1x/year when provided by OB/Gyn or PCP Ages: All Gender: F Hearing screening 92551, 92552, 92553, 92568, 92585, 92586 , , , , , Frequency: 1x/year Ages: 0 21 years Gender: M/F Hepatitis B screening 86704, 86706, 87340, 87341, G0499 All Frequency: 1x/year Ages: All Gender: M/F Hepatitis C screening 86803, 86804 All Frequency: 1x/year Ages: 18-79 Gender: M/F HIV Testing Serology: 86689, 86701, 86702, 86703, 87389, 87390, 87391, 87806 All Frequency: Unlimited Ages: All Gender: M/F Assays: 87534, 87535, 87636, 87537, 87538, 87539, S3645 All Frequency: 4x/year Ages: All Gender.

10 M/F Medical Management Page 10 Adapted Jan 2021 HIV screening G0432, G0433, G0435, G0445, G0475 , , , , , , , , , , , Frequency: Unlimited Ages: All Gender: M/F Human Papilloma Virus (HPV) screening 87623, 87624, 87625 , , , , , , , , , , , Frequency: 1x/year Ages: All Gender: F screening for Cervical cancer with Human Papillomavirus (HPV) Tests (paid when billed by a laboratory only) G0476 , , , , , Frequency: 5x/year Ages: 30 - 65 Gender: F Lead screening 83655 , , , , , , , , , , , Frequency: 1x/year Ages: 0-6 years Gender: M/F Lipid screening 80061, 82465, 83718, 83719, 83721, 84478 , , , , , , , , , , , , , , , Frequency: 1x/year Ages: All Gender: M/F Lung cancer screening 71250, 71271, G0296, G0297 (deleted 12/31/2020) , , , , , , , , Frequency: 1x/year Ages: 55 + Gender: M/F Mammography screening 77067 , Frequency: 1x/year Ages: 35+ years Gender: F Newborn screening : Hearing 92558 All Frequency: 1x/year Ages: 0-3 months Gender: M/F Newborn screening : Hypothyroidism 84437, 84443 All Frequency: 1x/year Ages: 0-3 months Gender: M/F Medical Management Page 11 Adapted Jan 2021 Newborn screening : PKU 84030, S3620 , , , Frequency: 1x/year Ag