Preventive Services List: I-Z

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

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Influenza Virus Vaccine and Administration

HCPCS/CPT Codes
  • 90653, 90662, 90672, 90674, 90682, 90685, 90686, 90687, 90688, 90756, Q2035, Q2036, Q2037, Q2038, Q2039 - Influenza Virus Vaccine
  • G0008 - Administration of influenza virus vaccine (allowable same as CPT 90471)
Frequency Once per influenza season (additional flu shots are covered if medically necessary)
Diagnosis Code Z23 - Encounter for immunization
Coverage All Medicare beneficiaries
Payment Copayment/coinsurance waived; Deductible waived
Resources
Roster Billing
  • Simplifies claims by allowing mass immunizers to submit one claim form with a list of several immunized beneficiaries
  • Use Medicare Beneficiary Identifiers (MBIs) to check eligibility and submit claims
Noridian Medicare Portal No

 

Initial Preventive Physical Examination (IPPE)

HCPCS/CPT Codes
  • G0402 - IPPE
  • G0403 - EKG for IPPE
  • G0404 - EKG tracing for IPPE
  • G0405 - EKG interpret & report for IPPE
Frequency Once in a lifetime and must be furnished no later than 12 months after effective date of first Medicare Part B coverage period
Coverage
  • All new Medicare beneficiaries within first 12 months of their first Medicare Part B coverage period
  • Performed by Physician, Physician Assistant (PA), Nurse Practitioner (NP), Clinical Nurse Specialist (CNS)
Payment
  • G0402 - Copayment/coinsurance waived; Deductible waived
  • G0403, G0404 and G0405 - Copayment/coinsurance applies; Deductible applies
Resources
Noridian Medicare Portal Yes - G0402, G0403, G0404, G0405

 

Intensive Behavioral Therapy (IBT) for Cardiovascular Disease

HCPCS/CPT Codes

G0446 - Annual, face-to-face intensive behavioral therapy for cardiovascular disease

Frequency Annually
Coverage
  • Beneficiaries competent at time of counseling; and
  • Furnished by qualified primary care physician or other primary care practitioner and in primary care setting
Therapy Components
  • Encouraging aspirin use for men ages 45-79 and women ages 55-79
  • High blood pressure screening for adults ages 18 and older; and
  • Intensive behavioral counseling to promote a healthy diet for adults with hypertension, advancing age, and other known risk factors for cardiovascular- and diet-related chronic disease
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 patient's interest in and willingness to change behavior
  4. Assist: Using behavior change techniques (self-help and/or counseling), aid 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 treatment plan as needed, including referral to more intensive or specialized treatment
Payment Copayment/coinsurance waived; Deductible waived
Resources
Noridian Medicare Portal Yes - G0446

 

Intensive Behavioral Therapy (IBT) for Obesity

HCPCS/CPT Codes
  • G0447 - Face-to-face behavioral counseling for obesity, 15 minutes
  • G0473 - Face-to-face behavioral counseling for obesity, group (two–10), 30 minutes
Frequency
  • First month: One face-to-face visit every week
  • Months two - six: One face-to-face visit every other week
  • Months seven - 12: One face-to-face visit every month if certain requirements are met

Notes:

  • At the six-month visit, reassessment of obesity and determination of amount of weight loss must be performed
  • To be eligible for additional face-to-face visits occurring once a month for additional six months, Medicare beneficiaries must have lost at least three kg
  • For Medicare beneficiaries who do not achieve weight loss of at least three kg during first six months, reassessment of their readiness to change and Body Mass Index (BMI) is appropriate after additional six-month period
Diagnosis Code
  • Z68.30 - Body mass index 30.0-30.9, adult
  • Z68.31 - Body mass index 31.0-31.9, adult
  • Z68.32 - Body mass index 32.0-32.9, adult
  • Z68.33 - Body mass index 33.0-33.9, adult
  • Z68.34 - Body mass index 34.0-34.9, adult
  • Z68.35 - Body mass index 35.0-35.9, adult
  • Z68.36 - Body mass index 36.0-36.9, adult
  • Z68.37 - Body mass index 37.0-37.9, adult
  • Z68.38 - Body mass index 38.0-38.9, adult
  • Z68.39 - Body mass index 39.0-39.9, adult
  • Z68.41 - Body mass index 40.0-44.9, adult
  • Z68.42 - Body mass index 45.0-49.9, adult
  • Z68.43 - Body mass index 50.0-59.9, adult
  • Z68.44 - Body mass index 60.0-69.9, adult; or
  • Z68.45 - Body mass index 70 or greater, adult
Coverage
  • Obesity (BMI = 30 kilograms per meter squared)
  • Competent and alert at time counseling is provided
  • Counseling furnished by qualified primary care physician or other primary care practitioner in 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 patient's interest in and willingness to change behavior
  4. Assist: Using behavior change techniques (self-help and/or counseling), aid patient in achieving agreed upon goals by acquiring 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 treatment plan as needed, including referral to more intensive or specialized treatment
Payment Copayment/coinsurance waived; Deductible waived
Resources
Noridian Medicare Portal Yes - G0447 and G0473

 

Lung Cancer Screening

HCPCS/CPT Codes
  • G0296 - Counseling visit to discuss need for lung cancer screening using low dose CT scan
  • G0297 - Low dose CT scan for lung cancer screening
Frequency Annually
First year: Before first screening, beneficiary must receive counseling and shared decision making visit
Subsequent years: Beneficiary must receive written order furnished during appropriate visit with physician or non-physician practitioner
Diagnosis Code

Z87.891 - Personal history of nicotine dependence

Coverage

Beneficiary must meet all of the following:

  • Age 55 - 77 years
  • Asymptomatic
  • Tobacco smoking history of at least 30 pack-years
  • Current smoker or one who has quit smoking within last 15 years
  • Written order received for lung cancer screening with low dose computed tomography
    • Beneficiary date of birth
    • Actual pack-year smoking history (number)
    • Current smoking status and for former smokers, number of years since quitting smoking
    • Statement that beneficiary is asymptotic, doesn't show signs or symptoms of lung cancer, and
    • National Provider Identifier (NPI) of ordering practitioner
Couseling Requirements
  • Determination of beneficiary eligibility including age, absence of signs or symptoms of lung cancer, a specific calculation of cigarette smoking pack-years; and if a former smoker, number of years since quitting
  • Shared decision making, including use of one or more decision aids, to include benefits and harms of screening, follow-up diagnostic testing, over-diagnosis, false positive rate, and total radiation exposure
  • Counseling on importance of adherence to annual screenings, impact of comorbidities and ability or willingness to undergo diagnosis and treatment
  • Counseling on importance of maintaining cigarette smoking abstinence if a former smoker; or importance of smoking cessation if current smoker and, if appropriate, furnishing of information about tobacco cessation interventions
  • If appropriate, furnishing of a written order for lung cancer screening
Payment Copayment/coinsurance waived; Deductible waived
Resources
Noridian Medicare Portal Yes - G0297

 

Medical Nutrition Therapy (MNT)

HCPCS/CPT Codes
  • 97802 - MNT; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes
  • 97803 - MNT; re-assessment and intervention, individual, face-to-face with the patient each 15 minutes
  • 97804 - MNT; group (two or more individual(s)), each 30 minutes
  • G0270 - MNT reassessment and subsequent intervention(s) for change in diagnosis, medical condition or treatment regimen, individual, each 15 minutes
  • G0271 - MNT reassessment and subsequent intervention(s) for change in diagnosis, medical condition or treatment regimen, group (two or more), each 30 minutes
Frequency First year: Three hours of one-on-one counseling
Subsequent years: Two hours
Coverage

Beneficiary must meet all of the following:

  • Referral received from treating physician; and
  • Diagnosed with diabetes or renal disease or has received kidney transplant within last three years
  • Service provided by registered dietitian or nutrition professional
Payment Copayment/coinsurance waived; Deductible waived
Resources
Noridian Medicare Portal No

 

Pneumococcal Vaccine and Administration

HCPCS/CPT Codes
  • 90670 - Pneumococcal Conjugate vaccine
  • 90732 - Pneumococcal polysaccharide vaccine
  • G0009 - Administration (allowable same as CPT 90471)
Frequency
  • Initial vaccine to beneficiaries who never received vaccine under Medicare Part B
  • Different, second vaccine one year after first vaccine was administered
Diagnosis Code

Z23 - Encounter for immunization

Coverage All Medicare beneficiaries are eligible
Payment Copayment/coinsurance waived; Deductible waived
Resources
Noridian Medicare Portal No

 

Prostate Cancer Screening

HCPCS/CPT Codes
  • G0102 - Digital Rectal Exam (DRE)
  • G0103 - Prostate Specific Antigen (PSA) test
Frequency Annually
Diagnosis Code

Z12.5 - Encounter for screening for malignant neoplasm of prostate

Coverage

Male beneficiaries aged 50 and older

  • Coverage begins day after 50th birthday
  • G0102 bundled into covered evaluation and management service when furnished on same day
Payment
  • G0102 - Copayment/coinsurance applies; Deductible applies
  • G0103 - Copayment/coinsurance waived; Deductible waived
Resources
Noridian Medicare Portal Yes - G0103

 

Screening Mammography

HCPCS/CPT Codes
  • 77063 - Screening digital breast tomosynthesis; bilateral (List separately in addition to code for primary procedure) (Use this as an add-on code to G0202 when tomosynthesis is used in addition to 2-D mammography)
  • 77067 - Screening mammography, bilateral (2-view film study of each breast) (Effective 01/01/18)
  • G0202 - Screening mammography, producing direct 2-D digital image, bilateral, all views (Valid prior to 01/01/18)
Frequency
  • Women aged 35 - 39: One baseline
  • Women 40 and over: Annually
Diagnosis Code

Z12.31 - Encounter for screening mammogram for malignant neoplasm of breast

Coverage All females aged 35 and older
Facilities
  • Must be certified by Food and Drug Administration (FDA)
  • Cannot release x-rays for interpretation to physicians not approved under certification number unless:
    • Patient requested transfer for second opinion
    • Patient moved to another part of country where next screening mammography will be performed
Payment Copayment/coinsurance waived; Deductible waived
Resources
Noridian Medicare Portal Yes - 77057 and G0202

 

Screening Pap Tests

HCPCS/CPT Codes
  • G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148 - Screening cytopathology, cervical or vaginal
  • P3000 - Screening Pap smear by technician under physician supervision
  • P3001 - Screening Pap smear requiring interpretation by physician
  • Q0091 - Screening Pap smear; obtaining, preparing and conveyance to lab
Frequency
  • Annually if at high risk for developing cervical or vaginal cancer or childbearing age with abnormal Pap test within past three years
    • High risk factors:
      • Early onset of sexual activity
      • Multiple sexual partners
      • History of sexually transmitted disease
      • Fewer than three negative or any pap smears within previous seven years
      • DES (diethylstilbestrol) exposed daughters of women who took DES during pregnancy
  • Every two years for women at normal risk
Diagnosis Code

High Risk

  • Z72.51 - High risk heterosexual behavior
  • Z72.52 - High risk homosexual behavior
  • Z72.53 - High risk bisexual behavior
  • Z77.21 - Contact with and (suspected) exposure to potentially hazardous body fluids
  • Z77.22 - Contact with and (suspected) exposure to environmental tobacco smoke (acute) (chronic)
  • Z77.9 - Contact with and (suspected) exposures hazardous to health
  • Z91.89 - Other specified personal risk factors, not elsewhere classified
  • Z92.89 - Personal history of other medical treatment

Low Risk

  • Z01.411 - Encounter for gynecological examination (general) (routine) with abnormal findings
  • Z01.419 - Encounter for gynecological examination (general) (routine) without abnormal findings
  • Z12.4 - Encounter for screening for malignant neoplasm of cervix
  • Z12.72 - Encounter for screening for malignant neoplasm of vagina
  • Z12.79 - Encounter for screening for malignant neoplasm of other genitourinary organs
  • Z12.89 - Encounter for screening for malignant neoplasm of other sites
Coverage
  • All female Medicare beneficiaries
    • Pap test and pelvic exam can be performed during same encounter
  • Ordered by Physician, Certified Nurse Midwife (CNM), PA, NP, CNS
Pap test and Pelvic exam can be performed during same encounter
Payment Copayment/coinsurance waived; Deductible waived
Resources
Noridian Medicare Portal Yes - G0123, G0143, G0144, G0145, G0147, G0148, P3000 and Q0091

 

Screening Pelvic Examinations

HCPCS/CPT Codes

G0101 - Cervical or vaginal cancer screening; pelvic and clinical breast examination

Frequency
  • Annually if at high risk for developing cervical or vaginal cancer or childbearing age with abnormal Pap test within past three years
    • High risk factors:
      • Early onset of sexual activity
      • Multiple sexual partners
      • History of sexually transmitted disease
      • Fewer than three negative or any pap smears within previous seven years
      • DES (diethylstilbestrol) exposed daughters of women who took DES during pregnancy
  • Every two years for women at normal risk
Coverage

All female Medicare beneficiaries

Pelvic exam and Pap test can be performed during same encounter

Exam Requirements

Must include seven (7) of the 11:

  1. Inspection and palpation of breasts for masses or lumps, tenderness, symmetry, or nipple discharge
  2. Digital rectal examination including sphincter tone, presence of hemorrhoids, and rectal masses

Pelvic examination (with or without specimen collection for smears and cultures) including:

  1. External genitalia (for example, general appearance, hair distribution, or lesions)
  2. Urethral meatus (for example, size, location, lesions, or prolapse).
  3. Urethra (for example, masses, tenderness, or scarring)
  4. Bladder (for example, fullness, masses, or tenderness)
  5. Vagina (for example, general appearance, estrogen effect, discharge lesions, pelvic support, cystocele, or rectocele)
  6. Cervix (for example, general appearance, lesions, or discharge)
  7. Uterus (for example, size, contour, position, mobility, tenderness, consistency, descent, or support)
  8. Adnexa/parametria (for example, masses, tenderness, organomegaly, or nodularity)
  9. Anus and perineum
Diagnosis Code

High Risk

  • Z72.51 - High risk heterosexual behavior
  • Z72.52 - High risk homosexual behavior
  • Z72.53 - High risk bisexual behavior
  • Z77.29 - Contact with and (suspected) exposure to other hazardous substances
  • Z77.9 - Contact with and (suspected) exposures hazardous to health
  • Z91.89 - Other specified personal risk factors, not elsewhere classified
  • Z92.89 -  Personal history of other medical treatment

Low Risk

  • Z01.411 - Encounter for gynecological examination (general) (routine) with abnormal findings
  • Z01.419 - Encounter for gynecological examination (general) (routine) without abnormal findings
  • Z12.4 - Encounter for screening for malignant neoplasm of cervix
  • Z12.72 - Encounter for screening for malignant neoplasm of vagina
  • Z12.79 - Encounter for screening for malignant neoplasm of other genitourinary organs
  • Z12.89 - Encounter for screening for malignant neoplasm of other sites
Payment Copayment/coinsurance waived; Deductible waived
Resources
Noridian Medicare Portal Yes - G0101

 

Sexually Transmitted Infections (STIs) Screening and High Intensity Behavioral Counseling (HIBC) to Prevent STIs

HCPCS/CPT Codes
  • 86631, 86632, 87110, 87270, 87320, 87490, 87491, 87810 - Chlamydia
  • 87590, 87591, 87850 - Neisseria gonorrhoeae
  • 87800 - Infectious agent detection by nucleic acid, multiple organisms; direct probe(s) technique
  • 86592 - Syphilis test, non-treponemal antibody; qualitative
  • 86593 - Syphilis test, non-treponemal, quantitative
  • 86780 - Treponema pallidum
  • 87340, 87341 - Hepatitis B (hepatitis B surface antigen)
  • G0445 - Semiannual high intensity behavioral counseling to prevent STIs, individual, face-to-face, includes education skills training and guidance on how to change sexual behavior, 30 minutes
Frequency
  • One annual occurrence of screening for chlamydia, gonorrhea, and syphilis in women at increased risk who are not pregnant
  • One annual occurrence of screening for syphilis in men at increased risk
  • Up to two occurrences per pregnancy of screening for chlamydia and gonorrhea in pregnant women who are at increased risk for STIs and continued increased risk for the second screening
  • One occurrence per pregnancy of screening for syphilis in pregnant women; up to two additional occurrences in the third trimester and at delivery if at continued increased risk for STIs
  • One occurrence per pregnancy of screening for hepatitis B in pregnant women; one additional occurrence at delivery if at continued increased risk for STIs
  • Up to two 20-30 minute, face-to-face HIBC sessions annually
Diagnosis Code
  • Z11.3 - Encounter for screening for infections with a predominantly sexual mode of transmission
  • Z72.51 - High risk heterosexual behavior
  • Z72.52 - High risk homosexual behavior
  • Z72.53 - High risk bisexual behavior
  • Z72.89 - Other problems related to lifestyle
  • 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 all of the following criteria:

  • Sexually active adolescents and adults at increased risk for STIs
  • Referred by primary care provider and provided by Medicare-eligible primary care provider in primary care setting
Payment Copayment/coinsurance waived; Deductible waived
Resources
Noridian Medicare Portal No

 

Ultrasound Screening for Abdominal Aortic Aneurysm (AAA)

HCPCS/CPT Codes

G0389 - Ultrasound exam for AAA screening

Frequency

Once in a lifetime

Coverage

Beneficiaries must meet both of the following criteria:

  • Certain risk factors for AAA
    • Family history
    • Male between ages of 65 and 75 who smoked at least 100 cigarettes during his lifetime
    • Manifests other risk factors
  • Receive referral from physician, physician assistant, nurse practitioner, or clinical nurse specialist
Payment Copayment/coinsurance waived; Deductible waived
Resources
Noridian Medicare Portal Yes - G0389

 

Resources

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

 

Last Updated Tue, 03 Mar 2020 16:23:30 +0000