Preventive Services List: A-H - JE Part B
Preventive Services List: A-H
Medicare covers the following preventive services and screenings, subject to certain eligibility and other limitations.
Alcohol Misuse Screening and Counseling
Category | Coverage and Benefit Resources |
---|---|
HCPCS/CPT Codes |
|
Frequency |
|
Coverage |
Screening: All Medicare beneficiaries are eligible Counseling: Beneficiaries who screen positive are eligible if:
|
Counseling Requirements |
Counseling is to be completed based on Five As Approach
|
Payment | Copayment/coinsurance waived; Deductible waived |
Resources | |
Noridian Medicare Portal | Yes - G0442 and G0443 |
Annual Wellness Visit (AWV)
Category | Coverage and Benefit Resources |
---|---|
HCPCS/CPT Codes |
|
Frequency |
|
Coverage |
|
Payment |
Copayment/coinsurance waived; Deductible waived |
Resources | |
Noridian Medicare Portal | Yes - G0438 and G0439 |
Bone Mass Measurements
Category | Coverage and Benefit Resources |
---|---|
HCPCS/CPT Codes |
|
Frequency | Every two years; more frequently if medically necessary |
Coverage |
Beneficiary must fall into one of the following categories:
|
Payment | Copayment/coinsurance waived; Deductible waived |
Resources | |
Noridian Medicare Portal | No |
Cardiovascular Disease Screening Tests
Category | Coverage and Benefit Resources |
---|---|
HCPCS/CPT Codes |
|
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
Category | Coverage and Benefit Resources |
---|---|
HCPCS/CPT Codes |
G0476 - Cervical cancer screening, all-inclusive HPV co-test with cytology (Pap smear) |
Frequency | Once every five years |
Diagnosis Code |
|
Coverage |
|
Payment | Copayment/coinsurance waived; Deductible waived |
Resources | |
Noridian Medicare Portal | No |
Colorectal Cancer Screening
Category | Coverage and Benefit Resources |
---|---|
Fecal Occult Blood Test |
CPT and HCPCS:
Frequency: Once every 12 months 82270 may be billed in place of G0328; however, both cannot be performed in same 12-month period Coverage:
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:
Coverage:
Payment: Copayment/coinsurance waived; Deductible waived |
Flexible Sigmoidoscopy |
HCPCS: G0104 - Flexible Sigmoidoscopy Frequency:
Coverage:
Payment: Copayment/coinsurance waived; Deductible waived
|
Screening Colonoscopy |
HCPCS:
Frequency:
Payment: Copayment/coinsurance waived; Deductible waived
|
Surveillance Colonoscopy |
Medicare does not specifically state whether a colonoscopy for "Surveillance" purposes is considered screening or diagnostic exclusively. Rather, it depends on the colonoscopy determination of billing:
Example:
When a screening colonoscopy (routine or high-risk screening) procedure becomes more consistent with a diagnostic colonoscopy (based on findings, biopsy, additional required intervention, etc.), the coding will change to a diagnostic procedure. Append -PT modifier to signify the intraprocedural status change. |
Screening Barium Enema |
HCPCS:
Frequency:
Coverage:
Payment: Copayment/coinsurance applies; Deductible waived |
High Risk Conditions |
|
Screening Becomes Diagnostic |
|
Anesthesia and Colonoscopy |
|
Incomplete/ Discontinued Procedure |
|
Evaluation and Management (E/M) Services |
Example 1:
Example 2:
|
Resources |
|
Noridian Medicare Portal | Yes - 81528, 82270, G0104, G0105, G0106, G0120, G0121 and G0328 |
Counseling to Prevent Tobacco Use
Category | Coverage and Benefit Resources |
---|---|
HCPCS/CPT Codes |
|
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 |
|
Coverage |
Outpatient and hospitalized beneficiaries who meet all of the following:
|
Payment | Copayment/coinsurance waived; Deductible waived |
Resources | |
Noridian Medicare Portal | No |
COVID-19 Vaccine, Monoclonal Antibodies and Administration
Category | Coverage and Benefit Resources |
---|---|
HCPCS/CPT Codes |
AstraZeneca
Eli Lilly
Genentech
GSK
Janssen
Moderna
Novavax
Pfizer-BioNTech
Regeneron
|
Coverage |
|
Payment |
Copayment/coinsurance waived; Deductible waived |
Pricing |
For a COVID-19 vaccine administration service the national payment rate is $40.00. MACs will apply geographically adjusted rates for payment purposes. For payment rates for COVID-19 vaccine administration, visit the COVID-19 Vaccines and Monoclonal Antibodies webpage on CMS. Payment for monoclonal antibody administration will be $309.60 (geographically adjusted to state/locality). Providers should not bill for the product if they received it for free. For more information on the monoclonal antibodies and their administration, visit the COVID-19 Vaccines and Monoclonal Antibodies webpage on CMS. |
Resources |
|
Noridian Medicare Portal | Yes - 93100-91309 (vaccines), 0001A-0094A (administration) |
Depression Screening
Category | Coverage and Benefit Resources |
---|---|
HCPCS/CPT Codes |
G0444 - Annual depression screening, 15 minutes |
Frequency | Annually |
Coverage |
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
Category | Coverage and Benefit Resources |
---|---|
HCPCS/CPT Codes |
|
Frequency |
Beneficiaries diagnosed with pre-diabetes: Two screening tests per year
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:
|
Payment | Copayment/coinsurance waived; Deductible waived |
Resources | |
Noridian Medicare Portal | Yes - 82947, 82950 and 82951 |
Diabetes Self-Management Training (DSMT)
Category | Coverage and Benefit Resources |
---|---|
HCPCS/CPT Codes |
|
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:
|
Payment | Copayment/coinsurance applies; Deductible applies |
Resources | |
Noridian Medicare Portal | No |
Glaucoma Screening
Category | Coverage and Benefit Resources |
---|---|
HCPCS/CPT Codes |
|
Frequency | Annually |
Diagnosis Code |
Z13.5 - Encounter for screening for eye and ear disorders |
Coverage |
Must fall into one category:
|
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
|
Payment | Copayment/coinsurance applies; Deductible applies |
Resources | |
Noridian Medicare Portal | Yes - G0117 and G0118 |
Hepatitis B Virus (HBV) Vaccine and Administration
Category | Coverage and Benefit Resources |
---|---|
HCPCS/CPT Codes |
|
Frequency | Scheduled doses required |
Diagnosis Code |
Z23 - Encounter for immunization |
Coverage |
Intermediate risk
High risk
Medicare beneficiaries currently positive for antibodies for hepatitis B are not eligible for this benefit |
Payment |
Copayment/coinsurance waived; Deductible waived G0010 allows $30 (2022) |
Resources | |
Noridian Medicare Portal | No |
Hepatitis C Virus (HCV) Screening
Category | Coverage and Benefit Resources |
---|---|
HCPCS/CPT Codes |
G0472 - Hepatitis C antibody screening, for individual at high risk and other covered indication(s) |
Frequency |
|
Diagnosis Code |
Initially high-risk
High risk with continued illicit injection drug use since prior screening
|
Coverage |
|
Payment | Copayment/coinsurance waived; Deductible waived |
Resources | |
Noridian Medicare Portal | Yes - G0472 |
Human Immunodeficiency Virus (HIV) Screening
Category | Coverage and Benefit Resources |
---|---|
HCPCS/CPT Codes |
|
Frequency |
|
Diagnosis Code |
Increased risk factors not reported
Increased risk factors reported
Pregnant Medicare beneficiaries
|
Coverage |
Beneficiaries must meet one of the following:
Noncoverage
|
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.
- CMS IOM, Publication 100-04, Chapter 18, Preventive and Screening Services - Internet Only Manual containing definition and listing of preventive and screening services.
- CMS Prevention General Information - This CMS website defines the preventive services and offers additional resources.
- CMS Preventive Services Educational Products - The CMS Medicare Learning Network ® (MLN) offers products, free of charge to view, download, print, and redistribute.
Last Updated Tue, 21 Mar 2023 17:45:57 +0000