Preventive Services List: A-H

Medicare covers the following preventive services and screenings, subject to certain eligibility and other limitations.

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Alcohol Misuse Screening and Counseling

HCPCS/CPT Codes
  • G0442 - Annual alcohol misuse screening, 15 minutes
  • G0443 - Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes
Frequency
  • G0442 - Annually
  • G0443 - For those who screen positive, four times per year
Coverage

Screening: All Medicare beneficiaries are eligible

Counseling: Beneficiaries who screen positive are eligible if:

  • They are competent and alert at the time counseling is provided; and
  • Counseling is furnished by qualified primary care physicians or other primary care practitioners in a primary care setting
Counseling Requirements

Counseling is to be completed based on Five As Approach

  1. Assess: Ask about or assess behavioral health risks and factors affecting choice of behavior change goals/methods.
  2. Advise: Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits.
  3. Agree: Collaboratively select appropriate treatment goals and methods based on the patient's interest in and willingness to change the behavior.
  4. Assist: Using behavior change techniques (self-help and/or counseling), aid the patient in achieving agreed upon goals by acquiring the skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate.
  5. Arrange: Schedule follow-up contacts (in person or by telephone) to provide ongoing assistance/support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment.
Payment Copayment/coinsurance waived; Deductible waived
Resources
Noridian Medicare Portal Yes - G0442 and G0443

 

Annual Wellness Visit (AWV)

HCPCS/CPT Codes
  • G0438 - Initial visit
  • G0439 - Subsequent visit
Frequency
  • G0438 - Once in a lifetime
  • G0439 - Annually
Coverage
  • Beneficiary not within 12 months after effective date of their first Medicare Part B coverage period
  • Has not received Initial Preventive Physical Examination (IPPE) or AWV within past 12 months
  • Performed by health professional:
    • Physician
    • Physician assistant
    • Nurse practitioner
    • Clinical nurse specialist
    • Medical professional (including health educator, registered dietitian, nutrition professional or other licensed practitioner) or team of such medical professionals, working under direct supervision of physician
No specific diagnosis code required; bill using the most appropriate diagnosis
Payment

Copayment/coinsurance waived; Deductible waived

Resources
Noridian Medicare Portal Yes - G0438 and G0439

 

Bone Mass Measurements

HCPCS/CPT Codes
  • 76977 - Ultrasound bone density measurement and interpretation, peripheral site(s), any method
  • 77078 - Computed tomography, bone mineral density study, one or more sites; axial skeleton (e.g., hips, pelvis, spine)
  • 77080 - Dual-energy X-ray absorptiometry (DXA), bone density study, one or more sites; axial skeleton (e.g., hips, pelvis, spine)
  • 77081 - DXA, bone density study, one or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel)
  • 77085 - DXA, bone density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine), including vertebral fracture assessment
  • G0130 - Single energy X-ray absorptiometry (SEXA) bone density study, one or more sites, appendicular skeleton (peripheral) (e.g., radius, wrist, heel)
Frequency Every two years; more frequently if medically necessary
Coverage

Beneficiary must fall into one of the following categories:

  • Women determined by physician or qualified non-physician practitioner to be estrogen deficient and at clinical risk for osteoporosis
  • Individuals with vertebral abnormalities
  • Individuals getting (or expecting to get) glucocorticoid therapy for more than three months
  • Individuals with primary hyperparathyroidism
  • Individuals being monitored to assess response to U.S. Food and Drug Administration (FDA)-approved osteoporosis drug therapy
Payment Copayment/coinsurance waived; Deductible waived
Resources
Noridian Medicare Portal No

 

Cardiovascular Disease Screening Tests

HCPCS/CPT Codes
  • 80061 - Lipid panel, this panel must include:
    • 82465 - Cholesterol, serum, total
    • 83718 - Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol)
    • 84478 - Triglycerides
Frequency Once every five years
Diagnosis Code

Z13.6 - Encounter for screening for cardiovascular disorders

Coverage All Medicare beneficiaries without apparent signs or symptoms of cardiovascular disease
Payment Copayment/coinsurance waived; Deductible waived
Resources
Noridian Medicare Portal Yes - 80061, 82465, 83718 and 84478

 

Cervical Cancer Screening with Human Papillomavirus (HPV) Tests

HCPCS/CPT Codes

G0476 - Cervical cancer screening, all-inclusive HPV co-test with cytology (Pap smear)

Frequency Once every five years
Diagnosis Code
  • Z11.51 - Encounter for screening for human papillomavirus; and
    • Z01.411 - Encounter for gynecological examination (general) (routine) with abnormal findings; or
    • Z01.419 - Encounter for gynecological examination (general) (routine) without abnormal findings
Coverage
  • Female beneficiaries aged 30 - 65 years
  • Asymptomatic
Payment Copayment/coinsurance waived; Deductible waived
Resources
Noridian Medicare Portal No

 

Colorectal Cancer Screening

Fecal Occult Blood Test

CPT and HCPCS:

  • 82270 - Blood, occult, by peroxidase activity (e.g., guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (e.g., patient was provided three cards or single triple card for consecutive collection)
  • G0328 - Fecal Occult Blood Test (FOBT), immunoassay, 1-3 simultaneous

Frequency: Once every 12 months

82270 may be billed in place of G0328; however, both cannot be performed in same 12-month period

Coverage:

  • Aged 50 and older at normal risk for developing colorectal cancer; or
  • At high risk for developing colorectal cancer

Payment: Copayment/coinsurance waived; Deductible waived

Cologuard Multitarget Stool DNA

CPT: 81528 - Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result

Frequency: Once every three years

Diagnosis:

  • Z12.11 - Encounter for screening for malignant neoplasm of colon; and
  • Z12.12 - Encounter for screening for malignant neoplasm of rectum

Coverage:

  • Aged 50-85 years
  • Asymptomatic
  • At average risk of developing colorectal cancer

Payment: Copayment/coinsurance waived; Deductible waived

Flexible Sigmoidoscopy

HCPCS: G0104 - Flexible Sigmoidoscopy

Frequency:

  • High risk: Once every 48 months
  • Not high risk: Once every 48 months (unless beneficiary does not meet criteria for high risk of developing colorectal cancer and beneficiary has had screening colonoscopy (G0121) within previous 10 years, screening flexible sigmoidoscopy is covered only after at least 119 months have passed following the month he/she received the G0121)

Coverage:

  • Aged 50 and older at normal risk for developing colorectal cancer; or
  • At high risk for developing colorectal cancer

Payment: Copayment/coinsurance waived; Deductible waived

Screening Colonoscopy

HCPCS:

  • G0105 - Colonoscopy (high risk)
  • G0121 - Colonoscopy (not high risk)

Frequency:

  • High risk: Once every 24 months (unless screening flexible sigmoidoscopy was performed, then covered only after at least 47 months)
  • Not high risk: Once every 10 years or 48 months after previous sigmoidoscopy

Payment: Copayment/coinsurance waived; Deductible waived

Screening Barium Enema

HCPCS:

  • G0106 - Barium Enema (alternative to G0104)
  • G0120 - Barium Enema (alternative to G0105)

Frequency:

  • High risk: Once every 24 months (when used instead of flexible sigmoidoscopy or colonoscopy)
  • Not high risk: Once every 48 months (when used instead of flexible sigmoidoscopy or colonoscopy)

Coverage:

  • Aged 50 and older at normal risk for developing colorectal cancer; or
  • At high risk for developing colorectal cancer

Payment: Copayment/coinsurance applies; Deductible waived

High Risk Conditions
  • Close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp
  • Family history of familial adenomatous polyposis
  • Family history of hereditary nonpolyposis colorectal cancer
  • Personal history of adenomatous polyps
  • Personal history of colorectal cancer
  • Personal history of inflammatory bowel disease, including Crohn's Disease and ulcerative colitis
Screening Becomes Diagnostic
  • Use diagnostic CPT/HCPCS code
  • Primary diagnosis is screening; Secondary diagnosis indicates abnormal finding
    • Link second diagnosis to diagnostic code
  • Append modifier PT to indicate screening turned diagnostic
  • Laboratory services associated with a diagnostic colonoscopy should bill an appropriate diagnosis that does not indicate screening. Modifiers PT and 33 are not used for lab or pathology services
Anesthesia and Colonoscopy
  • When a colonoscopy becomes diagnostic, anesthesia is reported using CPT 00811 with modifier PT. Bill with diagnostic CPT code (453xx series) and deductible only is waived
  • CPT 00812 (with no modifier) is used with screening codes. Both coinsurance and deductible are waived
  • Do not append modifier PT to other anesthesia CPTs 00730, 00740 and 00813
  • Modifier 33 is not recognized for any colonoscopy/anesthesia codes
Incomplete/ Discontinued Procedure
  • Use modifier 53 to indicate a colonoscopy cannot be completed due to unforeseen circumstances. Billed amount must also be reduced upon claim submission. Medicare allows one-half the value of code billed
  • If a procedure is cancelled before any prep was completed, this cannot be billed for
  • Ambulatory Surgical Centers must append modifier 73 or 74 to indicate discontinued procedure prior to/after anesthesia administration
Evaluation and Management (E/M) Services

Example 1:

  • Dr. A referred a beneficiary for a screening colonoscopy. Since beneficiary is new to Dr. B, he/she would like to bill for an E/M visit and colonoscopy
  • If colonoscopy is performed same day as E/M, E/M is bundled into colonoscopy. E/M is not a separate, identifiable service. Beneficiary was evaluated by Dr. A before being sent to Dr. B. A second opinion or decision is not being requested, only the colonoscopy

Example 2:

  • Dr. A referred a beneficiary for a screening colonoscopy. On that day, beneficiary complained about stomach pain and loose, bloody stool so Dr. B did a full exam first
  • In this case, a new patient visit may be billed. Modifier 25 is not required on new patient visits
Resources
Noridian Medicare Portal Yes - 81528, 82270, G0104, G0105, G0106, G0120, G0121 and G0328

 

Counseling to Prevent Tobacco Use

HCPCS/CPT Codes
  • 99406 - Smoking and tobacco-use cessation counseling visit; intermediate, greater than three minutes up to 10 minutes
  • 99407 - Smoking and tobacco-use cessation counseling visit; intensive, greater than 10 minutes
Frequency Two cessation attempts per year

Each attempt may include four intermediate or intensive sessions, with the total covering up to eight sessions per year
Diagnosis Codes
  • F17.210 - Nicotine dependence, cigarettes, uncomplicated
  • F17.211 - Nicotine dependence, cigarettes, in remission
  • F17.213 - Nicotine dependence, cigarettes, with withdrawal
  • F17.218 - Nicotine dependence, cigarettes, with other nicotine-induced disorders
  • F17.219 - Nicotine dependence, cigarettes, with unspecified nicotine-induced disorders
  • F17.220 - Nicotine dependence, chewing tobacco, uncomplicated
  • F17.221 - Nicotine dependence, chewing tobacco, in remission
  • F17.223 - Nicotine dependence, chewing tobacco, with withdrawal
  • F17.228 - Nicotine dependence, chewing tobacco, with other nicotine-induced disorders
  • F17.229 - Nicotine dependence, chewing tobacco, with unspecified nicotine-induced disorders
  • F17.290 - Nicotine dependence, other tobacco product, uncomplicated
  • F17.291 - Nicotine dependence, other tobacco product, in remission
  • F17.293 - Nicotine dependence, other tobacco product, with withdrawal
  • F17.298 - Nicotine dependence, other tobacco product, with other nicotine-induced disorders
  • F17.299 - Nicotine dependence, other tobacco product, with unspecified nicotine-induced disorders
  • T65.211A - Toxic effect of chewing tobacco, accidental (unintentional), initial encounter
  • T65.212A - Toxic effect of chewing tobacco, intentional self-harm, initial encounter
  • T65.213A - Toxic effect of chewing tobacco, assault, initial encounter
  • T65.214A - Toxic effect of chewing tobacco, undetermined, initial encounter
  • T65.221A - Toxic effect of tobacco cigarettes, accidental (unintentional), initial encounter
  • T65.222A - Toxic effect of tobacco cigarettes, intentional self-harm, initial encounter
  • T65.223A - Toxic effect of tobacco cigarettes, assault, initial encounter
  • T65.224A - Toxic effect of tobacco cigarettes, undetermined, initial encounter
  • T65.291A - Toxic effect of other tobacco and nicotine, accidental (unintentional), initial encounter
  • T65.292A - Toxic effect of other tobacco and nicotine, intentional self-harm, initial encounter
  • T65.293A - Toxic effect of other tobacco and nicotine, assault, initial encounter
  • T65.294A - Toxic effect of other tobacco and nicotine, undetermined, initial encounter; or
  • Z87.891 - Personal history of nicotine dependence, unspecified, uncomplicated
Coverage

Outpatient and hospitalized beneficiaries who meet all of the following:

  • Use tobacco
  • Competent and alert at time of counseling
  • Counseling furnished by qualified physician or other Medicare-recognized practitioner
Payment Copayment/coinsurance waived; Deductible waived
Resources
Noridian Medicare Portal No

 

Depression Screening

HCPCS/CPT Codes

G0444 - Annual depression screening, 15 minutes

Frequency Annually
Coverage
  • All Medicare beneficiaries are eligible
  • Must be furnished in primary care setting that has staff-assisted depression care supports in place to assure accurate diagnosis, effective treatment, and follow-up

Coverage is limited to screening services and does not include treatment options for depression or any diseases, complications, or chronic conditions resulting from depression, nor does it address therapeutic interventions such as pharmacotherapy, combination therapy (counseling and medications), or other interventions for depression

Depression Screening cannot be done the same time as the initial AWV or Initial Preventive Physical Exam (IPPE)

Payment

Copayment/coinsurance waived; Deductible waived

Resources
Noridian Medicare Portal Yes - G0444

 

Diabetes Screening

HCPCS/CPT Codes
  • 82947 - Glucose; quantitative, blood
  • 82950 - Glucose; post glucose dose
  • 82951 - Glucose; tolerance test, three specimens
Frequency

Beneficiaries diagnosed with pre-diabetes: Two screening tests per year

  • Use modifier TS to indicate beneficiary is pre-diabetic

Beneficiaries previously tested by not diagnosed with pre-diabetes or never tested: One screening per year

Diagnosis Code

Z13.1 - Encounter for screening for diabetes mellitus

Coverage

Medicare beneficiaries with certain risk factors or diagnosed with pre-diabetes

Risk factors:

  • Any one:
    • Hypertension
    • Dyslipidemia
    • Obesity
    • Previous identification of elevated impaired fasting glucose or glucose tolerance
  • Any two:
    • Overweight
    • Family history
    • Age 65 or older
    • History of gestational diabetes mellitus or delivering baby weighing over nine pounds
This screening is noncovered for beneficiaries previously diagnosed as diabetic
Payment Copayment/coinsurance waived; Deductible waived
Resources
Noridian Medicare Portal Yes - 82947, 82950 and 82951

 

Diabetes Self-Management Training (DSMT)

HCPCS/CPT Codes
  • G0108 - DSMT, individual, per 30 minutes
  • G0109 - DSMT, group (two or more people), per 30 minutes
Frequency Initial Year: Up to 10 hours of initial training within a continuous 12-month period

Subsequent Years: Up to two hours of follow-up training each year after the initial year
Coverage

Beneficiary must meet both of the following:

  • Diagnosed with diabetes
  • Receive order for DSMT from physician or qualified non-physician practitioner treating beneficiary's diabetes
Payment Copayment/coinsurance applies; Deductible applies
Resources
Noridian Medicare Portal No

 

Glaucoma Screening

HCPCS/CPT Codes
  • G0117 - By optometrist or ophthalmologist
  • G0118 - Under direct supervision of optometrist or ophthalmologist
Frequency Annually
Diagnosis Code

Z13.5 - Encounter for screening for eye and ear disorders

Coverage

Must fall into one category:

  • Have diabetes mellitus
  • Have family history of glaucoma
  • African-Americans aged 50 and older
  • Hispanic-Americans aged 65 and older
Exam Requirements

Medicare will pay for glaucoma screening examinations where they are furnished by or under direct supervision in office setting of an ophthalmologist or optometrist, who is legally authorized to perform services under State law

Screening for glaucoma is defined to include:

  • A dilated eye examination with an intraocular pressure measurement; and
  • A direct ophthalmoscopy examination, or a slit-lamp biomicroscopic examination
Payment Copayment/coinsurance applies; Deductible applies
Resources
Noridian Medicare Portal Yes - G0117 and G0118

 

Hepatitis B Virus (HBV) Vaccine and Administration

HCPCS/CPT Codes
  • 90739 - Hepatitis B vaccine, adult dosage (two dose schedule), for intramuscular use
  • 90740 - Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (three dose schedule), for intramuscular use
  • 90743 - Hepatitis B vaccine, adolescent (two dose schedule), for intramuscular use
  • 90744 - Hepatitis B vaccine, pediatric/adolescent dosage (three dose schedule), for intramuscular use
  • 90746 - Hepatitis B vaccine, adult dosage (three dose schedule), for intramuscular use
  • 90747 - Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (four dose schedule), for intramuscular use
  • G0010 - Administration of Hepatitis B vaccine
Frequency Scheduled doses required
Diagnosis Code

Z23 - Encounter for immunization

Coverage

Intermediate risk

  • Staff at institutions for mentally challenged
  • Workers who have frequent contact with blood or blood-derived body fluids

High risk

  • End Stage Renal Disease (ESRD) patients
  • Clients of institutions for mentally challenged
  • Someone who lives in same house as a hepatitis b virus carrier
  • Homosexual men
  • Someone who injects illicit drugs

Medicare beneficiaries currently positive for antibodies for hepatitis B are not eligible for this benefit

Payment Copayment/coinsurance waived; Deductible waived
Resources
Noridian Medicare Portal No

 

Hepatitis C Virus (HCV) Screening

HCPCS/CPT Codes

G0472 - Hepatitis C antibody screening, for individual at high risk and other covered indication(s)

Frequency
  • Annually only for high risk beneficiaries with continued illicit injection drug use since prior negative screening test
  • Once in a lifetime for beneficiaries born between 1945 and 1965 who are not considered high risk
  • Initial screening, regardless of birth year, who had a blood transfusion before 1992 and beneficiaries with current or past history of illicit injection drug use
Diagnosis Code

Initially high-risk

  • Z72.89 - Other problems related to lifestyle

High risk with continued illicit injection drug use since prior screening

  • Z72.89 - Other problems related to lifestyle; and
  • F19.20 - Other psychoactive substance dependence, uncomplicated
Coverage
  • Ordered by primary care physician or practitioner; and
  • Beneficiary must be either be:
    • High risk for HCV infection
      • Persons with current or past history of illicit injection drug use
      • History of receiving blood transfusion prior to 1992
    • Born between 1945 and 1965
Payment Copayment/coinsurance waived; Deductible waived
Resources
Noridian Medicare Portal Yes - G0472

 

Human Immunodeficiency Virus (HIV) Screening

HCPCS/CPT Codes
  • 80081 - Obstetric panel (includes HIV testing)
  • G0432 - Infectious agent antibody detection by enzyme immunoassay (EIA) technique
  • G0433 - Infectious agent antibody detection by enzyme-linked immunosorbent assay (ELISA) technique
  • G0435 - Infectious agent antibody detection by rapid antibody test
  • G0475 - HIV antigen/antibody, combination assay, screening
Frequency
  • Annually for beneficiaries between 15 - 65 years without regard to perceived risk
  • Annually for beneficiaries under 15 years and adults older than 65 who are at increased risk for HIV infection:
    • Men who have sex with men
    • Men and women having unprotected vaginal or anal intercourse
    • Past of present injection drug users
    • Men and women who exchange sex for money or drugs or have sex partners who do
    • Individuals whose past or present sex partners were HIV-infected, bisexual, or injection drug users,
    • Persons who have acquired or request testing for other sexually transmitted infectious diseases,
    • Persons with a history of blood transfusions between 1978 and 1985,
    • Persons who request an HIV test despite reporting no individual risk factors,
    • Persons with new sexual partners,
    • Persons who, based on individualized physician interview and examination
  • Pregnant beneficiaries covered three times during pregnancy
    • When diagnosed as pregnant
    • During third trimester
    • At labor, if ordered by clinician
Diagnosis Code

Increased risk factors not reported

  • Z11.4 - Encounter for screening for human immunodeficiency virus

Increased risk factors reported

  • Z11.4 - Encounter for screening for human immunodeficiency virus; and
  • Z72.89 - Other problems related to lifestyle
  • Z72.51 - High risk heterosexual behavior
  • Z72.52 - High risk homosexual behavior; or
  • Z72.53 - High risk bisexual behavior

Pregnant Medicare beneficiaries

  • Z11.4 - Encounter for screening for human immunodeficiency virus; and
  • Z34.00 - Encounter for supervision of normal first pregnancy, unspecified trimester
  • Z34.01 - Encounter for supervision of normal first pregnancy, first trimester
  • Z34.02 - Encounter for supervision of normal first pregnancy, second trimester
  • Z34.03 - Encounter for supervision of normal first pregnancy, third trimester
  • Z34.80 - Encounter for supervision of other normal pregnancy, unspecified trimester
  • Z34.81 - Encounter for supervision of other normal pregnancy, first trimester
  • Z34.82 - Encounter for supervision of other normal pregnancy, second trimester
  • Z34.83 - Encounter for supervision of other normal pregnancy, third trimester
  • Z34.90 - Encounter for supervision of normal pregnancy, unspecified, unspecified trimester
  • Z34.91 - Encounter for supervision of normal pregnancy, unspecified, first trimester
  • Z34.92 - Encounter for supervision of normal pregnancy, unspecified, second trimester
  • Z34.93 - Encounter for supervision of normal pregnancy, unspecified, third trimester
  • O09.90 - Supervision of high risk pregnancy, unspecified, unspecified trimester
  • O09.91 - Supervision of high risk pregnancy, unspecified, first trimester
  • O09.92 - Supervision of high risk pregnancy, unspecified, second trimester; or
  • O09.93 - Supervision of high risk pregnancy, unspecified, third trimester
Coverage

Beneficiaries must meet one of the following:

  • Beneficiaries at increased risk for HIV infection
  • Anyone who asks for test
  • Pregnant women

Noncoverage

  • Beneficiary with any known diagnosis of HIV-related illness
  • Beneficiary who has had screening within one year
  • Pregnant beneficiary who has had three specified screening tests within each respective term of pregnancy
Payment Copayment/coinsurance waived; Deductible waived
Resources
Noridian Medicare Portal Yes - G0475

 

Resources

CMS has developed educational resources that are available for the provider community.

 

Last Updated Mon, 19 Oct 2020 20:33:30 +0000