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Preventive Services

Medicare pays for many preventive services to keep beneficiaries healthy. Preventive services can find health problems early, when treatment works best, and can keep them from getting certain diseases. These services include exams, shots, lab tests, screenings, as well as, programs for health monitoring, and counseling and education to help them take care of their own health.

The Noridian Medicare Portal (NMP) offers some preventive history as part of the beneficiary eligibility inquiry. Not all codes are provided by CMS; however, the available codes are indicated in each table below.

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

All Medicare beneficiaries are eligible for screening.

Beneficiaries who screen positive are eligible for counseling 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
Payment Copayment/coinsurance waived; Deductible waived
Resources
Noridian Medicare Portal No

 

Annual Wellness Visit (AWV)

HCPCS/CPT Codes
  • G0438 – Initial visit
  • G0439 – Subsequent visit
Frequency
  • G0438 – Once in a lifetime
  • G0439 – Annually
Coverage

Medicare beneficiaries who are both:

  • Not within 12 months after effective date of their first Medicare Part B coverage period
  • Have not received Initial Preventive Physical Examination (IPPE) or AWV within past 12 months
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)
  • 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

 

Colorectal Cancer Screening

HCPCS/CPT Codes
  • 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
  • 82270 - Blood, occult, by peroxidase activity (e.g., guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (i.e., patient was provided 3 cards or single triple card for consecutive collection)
  • G0104 - Flexible Sigmoidoscopy
  • G0105 - Colonoscopy (high risk)
  • G0106 - Barium Enema (alternative to G0104)
  • G0120 - Barium Enema (alternative to G0105)
  • G0121 - Colonoscopy (not high risk)
  • G0328 - Fecal Occult Blood Test (FOBT), immunoassay, 1-3 simultaneous
  • G0464 - Colorectal cancer screening; stool-based DNA and fecal occult hemoglobin (e.g., KRAS, NDRG4 and BMP3)
Frequency

Normal Risk:

  • 81528 - Once every three years
  • G0328: Every year
  • G0104 - Once every four years (unless a screening colonoscopy has been performed and then Medicare may cover screening flexible sigmoidoscopy only after at least 119 months)
  • G0121 - Every 10 years (unless a screening flexible sigmoidoscopy has been performed and then Medicare may cover screening colonoscopy only after 47 months)
  • G0106 - As alternative to covered screening flexible sigmoidoscopy

High Risk:

  • G0328 - Every year
  • G0104 - Once every four years
  • G0105 - Every two years (unless a screening flexible sigmoidoscopy has been performed and then Medicare may cover screening colonoscopy only after at least 47 months)
  • G0120 - Screening barium enema (as alternative to covered screening flexible sigmoidoscopy or colonoscopy)
Diagnosis Code
  • 81528:
    • Z12.11 – Encounter for screening for malignant neoplasm of colon; and
    • Z12.12 – Encounter for screening for malignant neoplasm of rectum
Coverage
  • 81528 – All of the following:
    • Age 50 – 85 years
    • Asymptomatic
    • At average risk of developing colorectal cancer
  • G0104, G0105, G0106, G0120, G0121, G0328, G0464 – One of the following:
    • Age 50 and older at normal risk of developing colorectal cancer
    • At high risk for developing colorectal cancer
Payment
  • 81528, 82270, G0104, G0105, G0121, G0328, G0464
    • Copayment/coinsurance waived; Deductible waived
  • G0106 and G0120
    • Copayment/coinsurance applies; Deductible waived
Resources
Noridian Medicare Portal Yes – 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
  • F17.200 - Nicotine dependence, unspecified, uncomplicated
  • F17.201 - Nicotine dependence, unspecified, in remission
  • F17.210 - Nicotine dependence, cigarettes, uncomplicated
  • F17.211 - Nicotine dependence, cigarettes, in remission
  • F17.220 - Nicotine dependence, chewing tobacco, uncomplicated
  • F17.221 - Nicotine dependence, chewing tobacco, in remission
  • F17.290 - Nicotine dependence, other tobacco product, uncomplicated
  • F17.291 - Nicotine dependence, other tobacco product, in remission
  • 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 a primary care setting that has staff-assisted depression care supports in place to assure accurate diagnosis, effective treatment, and follow-up
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

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

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
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 Beneficiaries at intermediate or high risk for contracting hepatitis B
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
Diagnosis Code
  • Z72.89 – Other problems related to lifestyle; and
  • F19.20 – Other psychoactive substance dependence, uncomplicated
Coverage

Beneficiary must be either:

  • High risk for HCV infection
  • Born between 1945 and 1965
Payment Copayment/coinsurance waived; Deductible waived
Resources
Noridian Medicare Portal No

 

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
  • 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 the test
  • Pregnant women
Payment Copayment/coinsurance waived; Deductible waived
Resources
Noridian Medicare Portal No

 

Influenza Virus Vaccine and Administration

HCPCS/CPT Codes
  • 90630, 90653, 90654, 90655, 90656, 90657, 90661, 90662, 90672, 90673, 90674, 90685, 90686, 90687, 90688, Q2035, Q2036, Q2037, Q2038, Q2039 - Influenza Virus Vaccine
  • G0008 - Administration of influenza virus vaccine
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
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 the first 12 months of their first Medicare Part B coverage period
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
Payment Copayment/coinsurance waived; Deductible waived
Resources
Noridian Medicare Portal Yes – G0446

 

Intensive Behavioral Therapy 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
Payment Copayment/coinsurance waived; Deductible waived
Resources
Noridian Medicare Portal Yes – G0447

 

Lung Cancer Screening

HCPCS/CPT Codes
  • G0296 – Counseling visit to discuss need for lunch 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
Payment Copayment/coinsurance waived; Deductible waived
Resources
Noridian Medicare Portal No

 

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
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
Payment
  • G0102: Copayment/coinsurance applies; Deductible applies
  • G0103: Copayment/coinsurance waived; Deductible waived
Resources
Noridian Medicare Portal Yes – G0103

 

Screening for Cervical Cancer 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
Payment Copayment/coinsurance waived; Deductible waived
Resources
Noridian Medicare Portal No

 

Screening for Sexually Transmitted Infections (STIs) 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

 

Screening Mammography

HCPCS/CPT Codes
  • 77052 – Computer-aided detection with further review for interpretation; screening mammography
  • 77057 - Screening mammography, bilateral (two-view film study of each breast)
  • 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)
  • G0202 - Screening mammography, producing direct 2-D digital image, bilateral, all views
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
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
  • 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
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
  • Every two years for women at normal risk
Coverage All female Medicare beneficiaries
Diagnosis Code

High Risk:

  • 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
  • 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

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

 

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
  • 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 Aug 16, 2017