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ued)
Harva
rd P
ilgrim
Health
Care
—Pro
vider M
an
ual
B.1
7
Jan
uary 2
01
6
ME
MB
ER
CA
RE
—P
RO
TE
CT
ING
HE
ALT
H IN
FO
RM
AT
ION
Pa
tient P
rotectio
n a
nd
Affo
rda
ble C
are A
ct (F
edera
l Hea
lth C
are R
eform
)
Intro
du
ction
For e
mp
loye
r gro
up
s an
d n
on
-gro
up
mem
bers th
at re
new
ed
befo
re Ja
nu
ary 1
, 2011, b
en
efit ch
an
ges w
en
t into
effe
ct u
po
n re
new
al o
n o
r afte
r Sep
tem
ber 2
3, 2
010. Fo
r em
plo
yer g
rou
ps a
nd
no
n-g
rou
p m
em
bers th
at re
new
ed
on
or a
fter
Jan
uary 1
, 2011, th
ese
chan
ges w
en
t into
effe
ct on
Jan
uary 1
, 2011, e
xcep
t for th
e ch
ild d
ep
en
den
t cove
rag
e ch
an
ge a
nd
d
ura
ble
med
ical e
qu
ipm
en
t coin
sura
nce
chan
ges a
s no
ted
in th
e P
reve
ntive
Service
s info
rmatio
n b
elo
w. M
ost p
reve
ntive
ca
re se
rvices a
re co
vere
d w
ith n
o co
st sharin
g.
Harva
rd P
ilgrim
mem
bers h
ave
no
cost-sh
arin
g re
spo
nsib
ility wh
en
pre
ven
tive se
rvices a
re re
nd
ere
d b
y an
in-n
etw
ork
p
rovid
er. M
em
bers m
ay still b
e re
qu
ired
to p
ay a
cop
aym
en
t, ded
uctib
le o
r coin
sura
nce
for p
reve
ntive
service
s rece
ived
fro
m o
ut-o
f-netw
ork
pro
viders (P
PO
an
d P
OS p
lan
s), or fo
r no
n-p
reve
ntive
service
s rece
ived
in co
nju
nctio
n w
ith a
pre
-ve
ntive
service
s visit.
Em
plo
yer g
rou
ps m
ain
tain
ing
“g
ran
dfa
there
d” sta
tus u
nd
er th
e P
atie
nt P
rote
ction
an
d A
fford
ab
le C
are
Act, a
lso k
no
wn
as Fe
dera
l Health
Care
Refo
rm, m
ay b
e e
xem
pt fro
m ce
rtain
pro
vision
s.
Co
ve
rag
e a
nd
Se
rvice
s
All d
iag
no
sis cod
es o
f pre
ven
tive, scre
en
ing
, cou
nse
ling
, or w
elln
ess, sh
ou
ld b
e b
illed
in th
e p
rimary
po
sition
wh
en
in
dica
ted
.
Pre
ven
tive C
are
— H
arva
rd P
ilgrim
no
lon
ger im
po
ses co
st sharin
g o
n th
e fo
llow
ing
in-n
etw
ork
pre
ven
tive ca
re se
rvices:
Ch
ild D
ep
en
den
t Co
vera
ge —
Harva
rd P
ilgrim
pro
vides co
vera
ge to
child
dep
en
den
ts un
til ag
e 2
6. T
his ch
an
ge w
en
t in
to e
ffect fo
r all e
mp
loye
r gro
up
ren
ew
als a
fter Se
pte
mb
er 2
3, 2
010.
Wo
men
’s Pre
ven
tive S
erv
ices —
Effe
ctive fo
r pla
n ye
ars re
new
ing
on
or a
fter A
ug
ust 1
, 2012, H
arva
rd P
ilgrim
will co
ver
the fo
llow
ing
wo
men
’s pre
ven
tive se
rvices w
ith n
o m
em
ber co
st sharin
g w
hen
ren
dere
d b
y a p
articip
atin
g H
arva
rd P
il-g
rim p
rovid
er:
Du
rab
le M
ed
ical E
qu
ipm
en
t — T
here
are
no
an
nu
al d
olla
r limits fo
r the d
ura
ble
med
ical e
qu
ipm
en
t ben
efit. In
ad
di-
tion
, effe
ctive a
s of Ju
ly 1, 2
011, a
min
imu
m co
insu
ran
ce o
f 20%
was in
trod
uce
d fo
r this b
en
efit. If a
pla
n a
lread
y had
co
insu
ran
ce o
f 20%
or g
reate
r for d
ura
ble
med
ical e
qu
ipm
en
t pu
rchase
d fro
m a
netw
ork
pro
vider, th
ere
is no
chan
ge in
th
e m
em
ber co
st sharin
g fo
r this e
qu
ipm
en
t (sub
ject to
reg
ula
tory a
pp
rova
l for N
ew
Ham
psh
ire p
lan
s).
Life
time L
imits —
Th
ere
are
no
ag
gre
gate
lifetim
e d
olla
r limits o
r lifetim
e a
nd
an
nu
al d
olla
r ben
efit lim
its on
esse
ntia
l
Th
e fo
llow
ing
tab
les re
pre
sen
t service
s, by ca
teg
ory, th
at h
ave
been
iden
tified
as p
reve
ntive
in n
atu
re.
Rx C
overa
ge —
Un
der th
e M
em
ber’s R
x ben
efit, th
e fo
llow
ing
ben
efits a
re co
vere
d:
an
d q
uan
tity limits a
pp
ly.
(contin
ued)
Harva
rd P
ilgrim
Health
Care
—Pro
vider M
an
ual
B.1
8
Jan
uary 2
01
6
Ro
utin
e Health
Screen
ing
s
Ab
do
min
al A
ortic A
neu
rysm
Scre
en
ing
ICD
-9D
escrip
tion
Co
mm
en
ts
On
ce p
er life
time
Ro
utin
e m
ed
ical e
xam
ICD
-10
De
scriptio
nC
om
me
nts
Perso
nal h
istory o
f nico
tine d
ep
en
den
ceO
nce
per life
time
Z00.0
0En
cou
nte
r for g
en
era
l ad
ult m
ed
ical e
xam
inatio
n w
itho
ut a
bn
orm
al
find
ing
s
CP
T/H
CP
CS
De
scriptio
nC
om
me
nts
Ultra
sou
nd
, retro
perito
neal (e
.g., re
nal, a
orta
, no
des), re
al tim
e w
ith
imag
e d
ocu
men
tatio
n; co
mp
lete
IC
D-9
/10 co
des
Ultra
sou
nd
, retro
perito
neal (e
.g., re
nal, a
orta
, no
des), re
al tim
e w
ith
imag
e d
ocu
men
tatio
n; lim
ited
ab
do
min
al a
ortic a
neu
rysm (A
AA
) screen
ing
An
em
ia, Iro
n D
eficie
ncy
An
em
ia S
creen
ing
CP
T/H
CP
CS
De
scriptio
nC
om
me
nts
Blo
od
cou
nt; h
em
ato
crit (Hct)
Co
vere
d w
hen
bille
d w
ith o
ne o
f the
Blo
od
cou
nt; h
em
og
lob
in (H
gb
)
Asp
irin fo
r the P
reven
tion
of C
ard
iovascu
lar D
isease
De
scriptio
nC
om
me
nts
the p
ote
ntia
l ben
efit d
ue to
a re
du
ction
in m
yoca
rdia
l infa
rction
s o
utw
eig
hs th
e p
ote
ntia
l harm
du
e to
an
incre
ase
in g
astro
inte
stinal
hem
orrh
ag
e.
E&
M se
rvices co
des co
vere
d in
full
wh
en
cou
nse
ling
for a
spirin
use
.
th
e p
ote
ntia
l ben
efit o
f a re
du
ction
in isch
em
ic strokes o
utw
eig
hs th
e
po
ten
tial h
arm
of a
n in
crease
in g
astro
inte
stinal h
em
orrh
ag
e.
Bacte
riuria
Scre
en
ing
CP
T/H
CP
CS
De
scriptio
nC
om
me
nts
Urin
alysis; b
acte
riuria
screen
, exce
pt b
y cultu
re o
r dip
stick
Co
vere
d w
hen
bille
d w
ith o
ne o
f the
Beh
avio
ral C
ou
nse
ling
Inte
rven
tion
s an
d S
creen
ing
in P
rimary
Care
to R
ed
uce
Alco
ho
l Misu
se
ICD
-9D
escrip
tion
Co
mm
en
ts
Alco
ho
lism
Ro
utin
e m
ed
ical e
xam
ICD
-10
De
scriptio
nC
om
me
nts
Z00.0
0En
cou
nte
r for g
en
era
l ad
ult m
ed
ical e
xam
inatio
n w
itho
ut a
bn
orm
al
find
ing
s
En
cou
nte
r for scre
en
ing
for o
ther d
isord
er
ME
MB
ER
CA
RE
—P
RO
TE
CT
ING
HE
ALT
H IN
FO
RM
AT
ION
Pa
tien
t Pro
tectio
n a
nd
Affo
rda
ble
Ca
re A
ct (con
t.)
(contin
ued)
Harva
rd P
ilgrim
Health
Care
—Pro
vider M
an
ual
B.1
9
Jan
uary 2
01
6
CP
T/H
CP
CS
De
scriptio
nC
om
me
nts
to 3
0 m
inu
tes.
g
reate
r than
30 m
inu
tes.
Beh
avio
ral C
ou
nse
ling
to P
reven
t Sexu
ally
Tra
nsm
itted
Infe
ction
s
De
scriptio
nC
om
me
nts
Hig
h-in
ten
sity beh
avio
ral co
un
selin
g is re
com
men
ded
to p
reve
nt se
xu-
ally tra
nsm
itted
infe
ction
s (STIs) fo
r all se
xually a
ctive a
do
lesce
nts a
nd
fo
r ad
ults a
t incre
ase
d risk
for ST
Is.
Co
vere
d w
hen
bille
d se
para
tely o
r w
ith a
n E
&M
service
, inclu
ded
in
Beh
avio
ral C
ou
nse
ling
in P
rimary
Care
to P
rom
ote
a H
ealth
y D
iet
ICD
-9D
escrip
tion
Co
mm
en
ts
Inap
pro
pria
te d
iet a
nd
eatin
g h
ab
itsC
ove
red
wh
en
bille
d se
para
tely o
r w
ith a
n E
&M
service
ap
pen
ded
with
R
ou
tine m
ed
ical e
xam
ICD
-10
De
scriptio
nC
om
me
nts
Inap
pro
pria
te d
iet a
nd
eatin
g h
ab
itsC
ove
red
wh
en
bille
d se
para
tely o
r w
ith a
n E
&M
service
ap
pen
ded
with
Z00.0
0En
cou
nte
r for g
en
era
l ad
ult m
ed
ical e
xam
inatio
n w
itho
ut a
bn
orm
al
find
ing
s
CP
T/H
CP
CS
De
scriptio
nC
om
me
nts
Nu
trition
al co
un
selin
g
Co
vere
d w
hen
bille
d se
para
tely o
r w
ith a
n E
&M
service
ap
pen
ded
with
Med
ical n
utritio
n th
era
py; in
itial a
ssessm
en
t an
d in
terve
ntio
n, in
di-
Med
ical n
utritio
n th
era
py; re
-asse
ssmen
t an
d in
terve
ntio
n, in
divid
ual,
Med
ical n
utritio
n th
era
py; g
rou
p (2
or m
ore
ind
ividu
al(s), e
ach
30
min
ute
s
Pre
ven
tive m
ed
icine co
un
selin
g o
r risk fa
ctor re
du
ction
Bre
ast C
an
cer S
creen
ing
– Gen
etic C
ou
nse
ling
an
d E
valu
atio
n fo
r BR
CA
Testin
g
ICD
-9D
escrip
tion
Co
mm
en
ts
Malig
nan
t neo
pla
sm o
f specifie
d p
arts o
f perito
neu
m
Malig
nan
t neo
pla
sm o
f perito
neu
m, u
nsp
ecifie
d
Malig
nan
t neo
pla
sm o
f fallo
pia
n tu
be
Perso
nal h
istory o
f malig
nan
t of u
nsp
ecifie
d fe
male
gen
ital o
rgan
Perso
nal h
istory o
f malig
nan
t neo
pla
sm o
f ova
ry
Fam
ily histo
ry of m
alig
nan
t neo
pla
sm o
f bre
ast
Fam
ily histo
ry of m
alig
nan
t neo
pla
sm o
f gen
ital o
rgan
s
Fam
ily histo
ry of m
alig
nan
t neo
pla
sm o
f ova
ry
Ro
utin
e m
ed
ical e
xam
Gen
etic su
scep
tibility to
malig
nan
t neo
pla
sm
ICD
-10
De
scriptio
nC
om
me
nts
Perso
nal h
istory o
f malig
nan
t neo
pla
sm o
f ova
ry
ME
MB
ER
CA
RE
—P
RO
TE
CT
ING
HE
ALT
H IN
FO
RM
AT
ION
Pa
tien
t Pro
tectio
n a
nd
Affo
rda
ble
Ca
re A
ct (con
t.)
(contin
ued)
Harva
rd P
ilgrim
Health
Care
—Pro
vider M
an
ual
B.2
0
Jan
uary 2
01
6
ICD
-10
De
scriptio
nC
om
me
nts
Fam
ily histo
ry of m
alig
nan
t neo
pla
sm o
f bre
ast
Fam
ily histo
ry of m
alig
nan
t neo
pla
sm o
f oth
er g
en
ital o
rgan
s
Fam
ily histo
ry of m
alig
nan
t neo
pla
sm o
f ova
ry
Z00.0
0En
cou
nte
r for g
en
era
l ad
ult m
ed
ical e
xam
inatio
n w
itho
ut a
bn
orm
al
find
ing
s
Gen
etic su
scep
tibility to
malig
nan
t neo
pla
sm o
f bre
ast
CP
T/H
CP
CS
De
scriptio
nC
om
me
nts
BR
CA
1, B
RC
A2 (b
reast ca
nce
r 1 a
nd
2) (e
.g., h
ere
dita
ry bre
ast a
nd
o
varia
n ca
nce
r) gen
e a
nalysis; fu
ll seq
uen
ce a
nalysis a
nd
com
mo
n
BR
CA
1, B
RC
A2 (b
reast ca
nce
r 1 a
nd
2) (e
.g., h
ere
dita
ry bre
ast a
nd
BR
CA
1, B
RC
A2 (b
reast ca
nce
r 1 a
nd
2) (e
.g., h
ere
dita
ry bre
ast a
nd
va
rian
ts
BR
CA
1 (b
reast ca
nce
r 1) (e
.g., h
ere
dita
ry bre
ast a
nd
ova
rian
can
cer)
-
BR
CA
1 (b
reast ca
nce
r 1) (e
.g., h
ere
dita
ry bre
ast a
nd
ova
rian
can
cer)
gen
e a
nalysis; k
no
wn
fam
ilial va
rian
t
BR
CA
2 (b
reast ca
nce
r 2) (e
.g., h
ere
dita
ry bre
ast a
nd
ova
rian
can
cer)
gen
e a
nalysis; fu
ll seq
uen
ce a
nalysis
BR
CA
2 (b
reast ca
nce
r 2) (e
.g., h
ere
dita
ry bre
ast a
nd
ova
rian
can
cer)
gen
e a
nalysis; k
no
wn
fam
ilial va
rian
t
BR
CA
1, B
RC
A2 (b
reast ca
nce
r 1 a
nd
2) (e
.g., h
ere
dita
ry bre
ast a
nd
o
varia
n ca
nce
r) gen
e a
nalysis; fu
ll seq
uen
ce a
nalysis a
nd
full d
up
lica-
Here
dita
ry bre
ast ca
nce
r-rela
ted
diso
rders (e
.g., h
ere
dita
ry bre
ast
can
cer, h
ere
dita
ry ova
rian
can
cer, h
ere
dita
ry en
do
metria
l can
cer);
gen
om
ic seq
uen
ce a
nalysis p
an
el, m
ust in
clud
e se
qu
en
cing
of a
t least
Here
dita
ry bre
ast ca
nce
r-rela
ted
diso
rders (e
.g., h
ere
dita
ry bre
ast
can
cer, h
ere
dita
ry ova
rian
can
cer, h
ere
dita
ry en
do
metria
l can
cer);
Initia
l com
pre
hen
sive p
reve
ntive
med
icine e
valu
atio
n a
nd
man
ag
e-
men
t of a
n in
divid
ual in
clud
ing
an
ag
e a
nd
gen
der a
pp
rop
riate
Initia
l com
pre
hen
sive p
reve
ntive
med
icine e
valu
atio
n a
nd
man
ag
e-
men
t of a
n in
divid
ual in
clud
ing
an
ag
e a
nd
gen
der a
pp
rop
riate
Initia
l com
pre
hen
sive p
reve
ntive
med
icine e
valu
atio
n a
nd
man
ag
e-
men
t of a
n in
divid
ual in
clud
ing
an
ag
e a
nd
gen
der a
pp
rop
riate
ME
MB
ER
CA
RE
—P
RO
TE
CT
ING
HE
ALT
H IN
FO
RM
AT
ION
Pa
tien
t Pro
tectio
n a
nd
Affo
rda
ble
Ca
re A
ct (con
t.)
(contin
ued)
Harva
rd P
ilgrim
Health
Care
—Pro
vider M
an
ual
B.2
1
Jan
uary 2
01
6
CP
T/H
CP
CS
De
scriptio
nC
om
me
nts
Perio
dic co
mp
reh
en
sive p
reve
ntive
med
icine re
eva
luatio
n a
nd
man
-ag
em
en
t of a
n in
divid
ual in
clud
ing
an
ag
e a
nd
gen
der a
pp
rop
riate
Perio
dic co
mp
reh
en
sive p
reve
ntive
med
icine re
eva
luatio
n a
nd
man
-ag
em
en
t of a
n in
divid
ual in
clud
ing
an
ag
e a
nd
gen
der a
pp
rop
riate
Perio
dic co
mp
reh
en
sive p
reve
ntive
med
icine re
eva
luatio
n a
nd
man
-ag
em
en
t of a
n in
divid
ual in
clud
ing
an
ag
e a
nd
gen
der a
pp
rop
riate
Bre
astfe
ed
ing
–Prim
ary
Care
Inte
rven
tion
an
d E
qu
ipm
en
t to P
rom
ote
Bre
astfe
ed
ing
CP
T/H
CP
CS
De
scriptio
nC
om
me
nts
Po
st-partu
m visit
Ho
me visit fo
r new
bo
rn ca
re
Tu
bin
g fo
r bre
ast p
um
p, re
pla
cem
en
t
Ad
ap
ter fo
r bre
ast p
um
p, re
pla
cem
en
t
Cap
for b
reast p
um
p b
ottle
, rep
lace
men
t
Bre
ast sh
ield
an
d sp
lash
pro
tecto
r for u
se w
ith b
reast p
um
p,
rep
lace
men
t
Po
lycarb
on
ate
bo
ttle fo
r use
with
bre
ast p
um
p, re
pla
cem
en
t
Lock
ing
ring
for b
reast p
um
p, re
pla
cem
en
t
E0602
Bre
ast p
um
p, m
an
ual, a
ny typ
eTh
is is a p
urch
ase
on
ly item
. E0603
R
en
tal fo
r 3 m
on
ths, th
en
pu
mp
mu
st b
e re
turn
ed
to ve
nd
or a
t the e
nd
of
the re
nta
l perio
d.
Lacta
tion
classe
s Cerv
ical C
an
cer S
creen
ing
, Pap
Sm
ear
ICD
-9D
escrip
tion
Co
mm
en
ts
Ro
utin
e m
ed
ical e
xam
Co
vere
d w
hen
bille
d w
ith th
e liste
d
ICD
-9/1
0 d
x cod
es.
Ro
utin
e g
yneco
log
ical e
xam
inatio
n
En
cou
nte
r for P
ap
an
icola
ou
cervica
l smear to
con
firm fin
din
gs o
f re
cen
t no
rmal sm
ear fo
llow
ing
initia
l ab
no
rmal sm
ear
Screen
ing
for m
alig
nan
t neo
pla
sm o
f the ce
rvix
ICD
-10
De
scriptio
nC
om
me
nts
Z00.0
0En
cou
nte
r for g
en
era
l ad
ult m
ed
ical e
xam
inatio
n w
itho
ut a
bn
orm
al
find
ing
s
En
cou
nte
r for g
yneco
log
ical e
xam
inatio
n (g
en
era
l) (rou
tine) w
ith
ab
no
rmal fin
din
gs
En
cou
nte
r for g
yneco
log
ical e
xam
inatio
n (g
en
era
l) (rou
tine) w
itho
ut
ab
no
rmal fin
din
gs
ME
MB
ER
CA
RE
—P
RO
TE
CT
ING
HE
ALT
H IN
FO
RM
AT
ION
Pa
tien
t Pro
tectio
n a
nd
Affo
rda
ble
Ca
re A
ct (con
t.)
(contin
ued)
Harva
rd P
ilgrim
Health
Care
—Pro
vider M
an
ual
B.2
2
Jan
uary 2
01
6
En
cou
nte
r for ce
rvical sm
ear to
con
firm fin
din
gs o
f rece
nt n
orm
al
smear fo
llow
ing
initia
l ab
no
rmal sm
ear
En
cou
nte
r for scre
en
ing
for m
alig
nan
t neo
pla
sm o
f the ce
rvix
CP
T/H
CP
CS
De
scriptio
nC
om
me
nts
Cyto
path
olo
gy co
des ce
rvical o
r vag
inal.
Co
vere
d w
hen
bille
d w
ith th
e liste
d
ICD
-9/1
0 d
x cod
es.
Infe
ctiou
s ag
en
t dete
ction
, by n
ucle
ic acid
, pap
pillo
maviru
s.
G0101
Cervica
l or va
gin
al ca
nce
r screen
ing
; pelvic a
nd
clinica
l bre
ast
exa
min
atio
n.
G0123
Screen
ing
cytop
ath
olo
gy, ce
rvical o
r vag
inal (a
ny re
po
rting
system
), co
llecte
d in
pre
serva
tive flu
id, a
uto
mate
d th
in la
yer p
rep
ara
tion
, scre
en
ing
by cyto
tech
no
log
ist un
der p
hysicia
n su
pervisio
n.
Screen
ing
cytop
ath
olo
gy, ce
rvical o
r vag
inal (a
ny re
po
rting
system
), co
llecte
d in
pre
serva
tive flu
id, a
uto
mate
d th
in la
yer p
rep
ara
tion
, re
qu
iring
inte
rpre
tatio
n b
y ph
ysician
.
Screen
ing
cytop
ath
olo
gy sm
ears, ce
rvical o
r vag
inal, p
erfo
rmed
by
au
tom
ate
d syste
m, w
ith m
an
ual re
screen
ing
, req
uirin
g in
terp
reta
tion
b
y ph
ysician
.
Co
vere
d w
hen
bille
d w
ith th
e liste
d
ICD
-9/1
0 d
x cod
es.
Screen
ing
cytop
ath
olo
gy, ce
rvical o
r vag
inal (a
ny re
po
rting
system
), co
llecte
d in
pre
serva
tive flu
id, a
uto
mate
d th
in la
yer p
rep
ara
tion
, with
m
an
ual scre
en
ing
an
d re
screen
ing
by cyto
tech
no
log
ist un
der p
hysi-
cian
sup
ervisio
n.
Screen
ing
cytop
ath
olo
gy, ce
rvical o
r vag
inal (a
ny re
po
rting
system
), co
llecte
d in
pre
serva
tive flu
id, a
uto
mate
d th
in la
yer p
rep
ara
tion
, with
scre
en
ing
by a
uto
mate
d syste
m, u
nd
er p
hysicia
n su
pervisio
n.
Screen
ing
cytop
ath
olo
gy, ce
rvical o
r vag
inal (a
ny re
po
rting
system
), co
llecte
d in
pre
serva
tive flu
id, a
uto
mate
d th
in la
yer p
rep
ara
tion
, with
scre
en
ing
by a
uto
mate
d syste
m a
nd
man
ual re
screen
ing
un
der p
hysi-
cian
sup
ervisio
n.
Screen
ing
cytop
ath
olo
gy sm
ears, ce
rvical o
r vag
inal, p
erfo
rmed
by
au
tom
ate
d syste
m u
nd
er p
hysicia
n su
pervisio
n.
Screen
ing
cytop
ath
olo
gy sm
ears, ce
rvical o
r vag
inal, p
erfo
rmed
by
au
tom
ate
d syste
m w
ith m
an
ual re
screen
ing
.
Screen
ing
Pap
an
icola
ou
smear; o
bta
inin
g, p
rep
arin
g a
nd
con
veya
nce
o
f cervica
l or va
gin
al sm
ear to
lab
ora
tory.
Ch
lam
yd
ia In
fectio
n S
creen
ing
ICD
-9D
escrip
tion
Co
mm
en
ts
Pre
gn
an
cy dx co
des
Ro
utin
e m
ed
ical e
xam
Specia
l screen
ing
exa
min
atio
n fo
r oth
er sp
ecifie
d ch
lam
ydia
l dise
ase
s
Specia
l screen
ing
exa
min
atio
n fo
r un
specifie
d ch
lam
ydia
l dise
ase
ICD
-10
De
scriptio
nC
om
me
nts
En
cou
nte
r for su
pervisio
n o
f no
rmal first p
reg
nan
cy, un
specifie
d
trimeste
r
En
cou
nte
r for su
pervisio
n o
f oth
er n
orm
al p
reg
nan
cy, un
specifie
d
trimeste
r
Z33.1
Pre
gn
an
t State
, incid
en
tal
Sup
ervisio
n o
f pre
gn
an
cy with
histo
ry of in
fertility, u
nsp
ecifie
d
trimeste
r
Sup
ervisio
n o
f pre
gn
an
cy with
histo
ry of e
ctop
ic or m
ola
r pre
gn
an
cy, u
nsp
ecifie
d trim
este
r
Sup
ervisio
n o
f pre
gn
an
cy with
oth
er p
oo
r rep
rod
uctive
or o
bste
tric h
istory, first trim
este
r
ME
MB
ER
CA
RE
—P
RO
TE
CT
ING
HE
ALT
H IN
FO
RM
AT
ION
Pa
tien
t Pro
tectio
n a
nd
Affo
rda
ble
Ca
re A
ct (con
t.)
(contin
ued)
Harva
rd P
ilgrim
Health
Care
—Pro
vider M
an
ual
B.2
3
Jan
uary 2
01
6
ICD
-10
De
scriptio
nC
om
me
nts
Sup
ervisio
n o
f pre
gn
an
cy with
gra
nd
mu
ltiparity, u
nsp
ecifie
d
trimeste
r
Sup
ervisio
n o
f pre
gn
an
cy with
histo
ry of p
re-te
rm la
bo
r, first trim
este
r
Sup
ervisio
n o
f pre
gn
an
cy with
histo
ry of e
ctop
ic or m
ola
r pre
gn
an
cy, u
nsp
ecifie
d trim
este
r
Sup
ervisio
n o
f pre
gn
an
cy with
oth
er p
oo
r rep
rod
uctive
or o
bste
tric h
istory, first trim
este
r
Sup
ervisio
n o
f pre
gn
an
cy with
insu
fficien
t an
ten
ata
l care
, un
specifie
d
trimeste
r
Sup
ervisio
n o
f eld
erly p
rimig
ravid
a, u
nsp
ecifie
d trim
este
r
Sup
ervisio
n o
f eld
erly m
ultig
ravid
a, u
nsp
ecifie
d trim
este
r
Sup
ervisio
n o
f you
ng
prim
igra
vida, u
nsp
ecifie
d trim
este
r
Sup
ervisio
n o
f you
ng
mu
ltigra
vida, u
nsp
ecifie
d trim
este
r
Sup
ervisio
n o
f pre
gn
an
cy resu
lting
from
assiste
d re
pro
du
ctive te
chn
ol-
og
y, un
specifie
d trim
este
r
Sup
ervisio
n o
f pre
gn
an
cy with
histo
ry of in
ute
ro p
roce
du
re d
urin
g
pre
viou
s pre
gn
an
cy, un
specifie
d trim
este
r
Pre
gn
an
cy with
inco
nclu
sive fe
tal via
bility, n
ot a
pp
licab
le o
r u
nsp
ecifie
d
Sup
ervisio
n o
f oth
er h
igh
risk p
reg
nan
cies, u
nsp
ecifie
d trim
este
r
Sup
ervisio
n o
f hig
h risk
pre
gn
an
cy, un
specifie
d, u
nsp
ecifie
d trim
este
r
En
cou
nte
r for g
yneco
log
ical e
xam
inatio
n (g
en
era
l) (rou
tine) w
ith
ab
no
rmal fin
din
gs
En
cou
nte
r for g
yneco
log
ical e
xam
inatio
n (g
en
era
l) (rou
tine) w
itho
ut
ab
no
rmal fin
din
gs
En
cou
nte
r for scre
en
ing
for o
ther in
fectio
us a
nd
para
sitic dise
ase
s
En
cou
nte
r for scre
en
ing
for o
ther in
fectio
us a
nd
para
sitic dise
ase
s
CP
T/H
CP
CS
De
scriptio
nC
om
me
nts
An
tibo
dy; C
hla
myd
ia.
All p
reg
an
an
t wo
men
— d
x cod
es
Co
vere
d w
hen
bille
d w
ith e
ither a
co
de).
An
tibo
dy; C
hla
myd
ia, Ig
M.
Cu
lture
, Ch
lam
ydia
, an
y sou
rce.
Infe
ctiou
s ag
en
t an
tigen
dete
ction
by im
mu
no
fluo
resce
nt te
chn
iqu
e;
Ch
lam
ydia
trach
om
atis.
-
niq
ue, q
ualita
tive o
r sem
iqu
an
titative
, mu
ltiple
step
meth
od
; Ch
la-
myd
ia tra
cho
matis.
Infe
ctiou
s ag
en
t Ch
lam
ydia
pn
eu
mo
nia
e.
trach
om
atis, d
irect p
rob
e te
chn
iqu
e.
trach
om
atis, a
mp
lified
pro
be te
chn
iqu
e.
trach
om
atis, q
uan
tificatio
n.
Ch
ole
stero
l Scre
en
ing
(Lipid
Diso
rders S
creen
ing
)
ICD
-9D
escrip
tion
Co
mm
en
ts
Ro
utin
e m
ed
ical e
xam
ME
MB
ER
CA
RE
—P
RO
TE
CT
ING
HE
ALT
H IN
FO
RM
AT
ION
Pa
tien
t Pro
tectio
n a
nd
Affo
rda
ble
Ca
re A
ct (con
t.)
(contin
ued)
Harva
rd P
ilgrim
Health
Care
—Pro
vider M
an
ual
B.2
4
Jan
uary 2
01
6
Screen
ing
for lip
oid
diso
rders
ICD
-10
De
scriptio
nC
om
me
nts
Z00.0
0En
cou
nte
r for g
en
era
l ad
ult m
ed
ical e
xam
inatio
n w
itho
ut a
bn
orm
al
find
ing
s
Z13.2
20
En
cou
nte
r for scre
en
ing
for lip
oid
diso
rders
CP
T/H
CP
CS
De
scriptio
nC
om
me
nts
Lipid
pan
el. T
his p
an
el m
ust in
clud
e th
e fo
llow
ing
: Ch
ole
stero
l,
d
x cod
es a
nd
ad
ditio
nal crite
ria
listed
Ch
ole
stero
l, seru
m o
r wh
ole
blo
od
, tota
l
d
x cod
es a
nd
ad
ditio
nal crite
ria
listed
Trig
lycerid
es
Co
lore
ctal C
an
cer S
creen
ing
(Feca
l Occu
lt Blo
od
Testin
g, S
igm
oid
osco
py o
r Co
lon
osco
py)
No
te: D
iag
no
sis mu
st be b
illed
in th
e p
rimary
po
sition
.
ICD
-9D
escrip
tion
Co
mm
en
ts
Small in
testin
e to
ulce
rative
colitis, u
nsp
ecifie
d
Perso
nal h
istory o
f malig
nan
t neo
pla
sm o
f un
specifie
d site
in g
astro
-in
testin
al tra
ct
Perso
nal h
istory o
f malig
nan
t neo
pla
sm o
f larg
e in
testin
e
Perso
nal h
istory o
f malig
nan
t neo
pla
sm o
f rectu
m, re
ctosig
mo
id ju
nc-
tion
, an
d a
nu
s
Histo
ry of co
lon
ic po
lyps
Fam
ily histo
ry of m
alig
nan
t neo
pla
sm o
f gastro
inte
stinal tra
ct
Fam
ily hx C
A N
OS
Fam
ily histo
ry, colo
nic p
olyp
s
Fam
ily histo
ry, oth
er d
igestive
diso
rders
Ro
utin
e m
ed
ical e
xam
Screen
ing
for m
alig
nan
t neo
pla
sm o
f the re
ctum
CA
screen
ing
NEC
Specia
l screen
ing
for m
alig
nan
t neo
pla
sms, in
testin
e, u
nsp
ecifie
d
Specia
l screen
ing
for m
alig
nan
t neo
pla
sms, co
lon
Specia
l screen
ing
for m
alig
nan
t neo
pla
sms, sm
all in
testin
e
CA
screen
ing
NO
S
ICD
-10
De
scriptio
nC
om
me
nts
Ulce
rative
(chro
nic) p
an
colitis w
itho
ut co
mp
licatio
ns
Oth
er u
lcera
tive co
litis with
ou
t com
plica
tion
s
Ulce
rative
(chro
nic) p
roctitis w
itho
ut co
mp
licatio
ns
Ulce
rative
(chro
nic) re
ctosig
mo
iditis w
itho
ut co
mp
licatio
ns
Infla
mm
ato
ry po
lyps o
f colo
n w
itho
ut co
mp
licatio
ns
ME
MB
ER
CA
RE
—P
RO
TE
CT
ING
HE
ALT
H IN
FO
RM
AT
ION
Pa
tien
t Pro
tectio
n a
nd
Affo
rda
ble
Ca
re A
ct (con
t.)
(contin
ued)
Harva
rd P
ilgrim
Health
Care
—Pro
vider M
an
ual
B.2
5
Jan
uary 2
01
6
ICD
-10
De
scriptio
nC
om
me
nts
Left sid
ed
colitis w
itho
ut co
mp
licatio
ns
Ulce
rative
colitis, u
nsp
ecifie
d, w
itho
ut co
mp
licatio
ns
Perso
nal h
istory o
f malig
nan
t neo
pla
sm o
f un
specifie
d d
igestive
org
an
Perso
nal h
istory o
f oth
er m
alig
nan
t neo
pla
sm o
f larg
e in
testin
e
Perso
nal h
istory o
f oth
er m
alig
nan
t neo
pla
sm o
f rectu
m, re
ctosig
mo
id
jun
ction
, an
d a
nu
s
Perso
nal h
istory o
f colo
nic p
olyp
s
Fam
ily histo
ry of m
alig
nan
t neo
pla
sm, u
nsp
ecifie
d
Fam
ily histo
ry of co
lon
ic po
lyps
Fam
ily histo
ry of o
ther d
isease
s of th
e d
igestive
system
Z00.0
0En
cou
nte
r for g
en
era
l ad
ult m
ed
ical e
xam
inatio
n w
itho
ut a
bn
orm
al
find
ing
s
Z12.1
2En
cou
nte
r for scre
en
ing
for m
alig
nan
t neo
pla
sm o
f rectu
m
En
cou
nte
r for scre
en
ing
for m
alig
nan
t neo
pla
sm o
f oth
er site
s
Z12.1
0En
cou
nte
r for scre
en
ing
for m
alig
nan
t neo
pla
sm o
f inte
stinal tra
ct, u
nsp
ecifie
d
Z12.1
1En
cou
nte
r for scre
en
ing
for m
alig
nan
t neo
pla
sm o
f colo
n
Z12.1
3En
cou
nte
r for scre
en
ing
for m
alig
nan
t neo
pla
sm o
f small in
testin
e
En
cou
nte
r for scre
en
ing
for m
alig
nan
t neo
pla
sm, site
un
specifie
d
Re
ve
nu
e
Co
de
sD
escrip
tion
Co
mm
en
ts
Ph
arm
acy
o
ne o
f the IC
D 9
/10 d
x cod
es liste
d
An
esth
esia
Reco
very ro
om
CP
T/H
CP
CS
De
scriptio
nC
om
me
nts
An
esth
esia
for lo
wer in
testin
al e
nd
osco
pic p
roce
du
res, e
nd
osco
pe
intro
du
ced
dista
l to d
uo
den
um
.
Co
lon
en
do
scop
y.
Co
lon
osco
py th
rou
gh
stom
a; w
ith b
iop
sy, sing
le o
r mu
ltiple
.
Co
lon
osco
py th
rou
gh
stom
a; w
ith re
mo
val o
f tum
or(s), p
olyp
(s), or
oth
er le
sion
(s) by h
ot b
iop
sy force
ps o
r bip
ola
r cau
tery.
Co
lon
osco
py th
rou
gh
stom
a; w
ith re
mo
val o
f tum
or(s), p
olyp
(s), or
oth
er le
sion
(s) by sn
are
tech
niq
ue.
Co
lon
osco
py th
rou
gh
stom
a; w
ith re
mo
val o
f tum
or(s), p
olyp
(s), or
oth
er le
sion
(s) by sn
are
tech
niq
ue.
Pro
ctosig
mo
ido
scop
y, rigid
; with
bio
psy, sin
gle
or m
ultip
le.
Pro
ctosig
mo
ido
scop
y, rigid
; with
bio
psy, sin
gle
or m
ultip
le.
Pro
ctosig
mo
ido
scop
y, rigid
; with
rem
ova
l of sin
gle
tum
or, p
olyp
, or
oth
er le
sion
by h
ot b
iop
sy force
ps o
r bip
ola
r cau
tery.
ME
MB
ER
CA
RE
—P
RO
TE
CT
ING
HE
ALT
H IN
FO
RM
AT
ION
Pa
tien
t Pro
tectio
n a
nd
Affo
rda
ble
Ca
re A
ct (con
t.)
(contin
ued)
Harva
rd P
ilgrim
Health
Care
—Pro
vider M
an
ual
B.2
6
Jan
uary 2
01
6
CP
T/H
CP
CS
De
scriptio
nC
om
me
nts
Pro
ctosig
mo
ido
scop
y, rigid
; with
rem
ova
l of sin
gle
tum
or, p
olyp
, or
oth
er le
sion
by sn
are
tech
niq
ue.
o
ne o
f the IC
D-9
/10 d
x cod
es liste
d
Pro
ctosig
mo
ido
scop
y, rigid
; with
rem
ova
l of m
ultip
le tu
mo
rs, po
lyps,
or o
ther le
sion
s by h
ot b
iop
sy force
ps, b
ipo
lar ca
ute
ry or sn
are
te
chn
iqu
e.
Pro
ctosig
mo
ido
scop
y, rigid
; with
ab
latio
n o
f tum
or(s), p
olyp
(s), or
oth
er le
sion
(s) no
t am
en
ab
le to
rem
ova
l by h
ot b
iop
sy force
ps, b
ipo
-la
r cau
tery o
r snare
tech
niq
ue (e
.g., la
ser).
Sigm
oid
osco
py, fle
xible
; dia
gn
ostic, w
ith o
r with
ou
t colle
ction
of
specim
en
(s) by b
rush
ing
or w
ash
ing
.
Sigm
oid
osco
py, fle
xible
; with
bio
psy, sin
gle
or m
ultip
le.
Sigm
oid
osco
py, fle
xible
; with
rem
ova
l of fo
reig
n b
od
y.
Sigm
oid
osco
py, fle
xible
; with
rem
ova
l of tu
mo
r(s), po
lyp(s), o
r oth
er
lesio
n(s) b
y ho
t bio
psy fo
rcep
s or b
ipo
lar ca
ute
ry.
Sigm
oid
osco
py, fle
xible
; with
rem
ova
l of tu
mo
r(s), po
lyp(s), o
r oth
er
lesio
n(s) b
y snare
tech
niq
ue.
Sigm
oid
osco
py, fle
xible
; with
ab
latio
n o
f tum
or(s), p
olyp
(s), or o
ther
lesio
n(s) n
ot a
men
ab
le to
rem
ova
l by h
ot b
iop
sy force
ps, b
ipo
lar ca
u-
tery o
r snare
tech
niq
ue.
Sigm
oid
osco
py, fle
xible
; with
en
do
scop
ic ultra
sou
nd
exa
min
atio
n.
Sigm
oid
osco
py, fle
xible
; with
tran
sen
do
scop
ic ultra
sou
nd
gu
ided
Co
lon
osco
py, fle
xible
, pro
ximal to
sple
nic fle
xure
; dia
gn
ostic, w
ith
or w
itho
ut co
llectio
n o
f specim
en
(s) by b
rush
ing
or w
ash
ing
, with
or
with
ou
t colo
n d
eco
mp
ressio
n (se
para
te p
roce
du
re).
Co
lon
osco
py, fle
xible
, pro
ximal to
sple
nic fle
xure
; with
bio
psy, sin
gle
o
r mu
ltiple
.
Co
lon
osco
py, fle
xible
, pro
ximal to
sple
nic fle
xure
; with
ab
latio
n o
f tu
mo
r(s), po
lyp(s), o
r oth
er le
sion
(s) no
t am
en
ab
le to
rem
ova
l by h
ot
bio
psy fo
rcep
s, bip
ola
r cau
tery o
r snare
tech
niq
ue.
Co
lon
osco
py, fle
xible
, pro
ximal to
sple
nic fle
xure
; with
rem
ova
l of
tum
or(s), p
olyp
(s), or o
ther le
sion
(s) by h
ot b
iop
sy force
ps o
r bip
ola
r ca
ute
ry.
Co
lon
osco
py, fle
xible
, pro
ximal to
sple
nic fle
xure
; with
rem
ova
l of
tum
or(s), p
olyp
(s), or o
ther le
sion
(s) by sn
are
tech
niq
ue.
Blo
od
, occu
lt, by p
ero
xidase
activity (e
.g., g
uaia
c), qu
alita
tive; fe
ces,
con
secu
tive co
llecte
d sp
ecim
en
s with
sing
e d
ete
rmin
atio
n, fo
r co
lore
ctal n
eo
pla
sm scre
en
ing
(i.e., p
atie
nt w
as p
rovid
ed
thre
e ca
rds
or sin
gle
triple
card
for co
nse
cutive
colle
ction
.
Blo
od
, occu
lt, by p
ero
xidase
activity (e
.g., g
uaia
c), qu
alita
tive, fe
ces,
1-3
simu
ltan
eo
us d
ete
rmin
atio
ns, p
erfo
rmed
for o
ther th
an
colo
recta
l n
eo
pla
sm scre
en
ing
.
Blo
od
, occu
lt, by fe
cal h
em
og
lob
in d
ete
rmin
ed
by im
mu
no
assa
y, q
ualita
tive, fe
ces, 1
-3 sim
ulta
neo
us d
ete
rmin
atio
ns.
Co
lore
ctal ca
nce
r screen
ing
; flexib
le sig
mo
ido
scop
y.
Co
lore
ctal ca
nce
r screen
ing
; colo
no
scop
y of in
divid
ual a
t hig
h risk
.
G0106
-
osco
py, b
ariu
m e
nem
a.
G0120
-
cop
y, bariu
m e
nem
a.
G0121
Co
lore
ctal ca
nce
r screen
ing
; colo
no
scop
y on
ind
ividu
al n
ot m
eetin
g
criteria
for h
igh
risk.
ME
MB
ER
CA
RE
—P
RO
TE
CT
ING
HE
ALT
H IN
FO
RM
AT
ION
Pa
tien
t Pro
tectio
n a
nd
Affo
rda
ble
Ca
re A
ct (con
t.)
(contin
ued)
Harva
rd P
ilgrim
Health
Care
—Pro
vider M
an
ual
B.2
7
Jan
uary 2
01
6
CP
T/H
CP
CS
De
scriptio
nC
om
me
nts
G0122
Co
lore
ctal ca
nce
r screen
ing
; bariu
m e
nem
a.
Co
lore
ctal ca
nce
r screen
ing
; feca
l-occu
lt blo
od
test, im
mu
no
assa
y, 1-3
sim
ulta
neo
us d
ete
rmin
atio
ns.
Inje
ction
, mep
erid
ine H
Cl, p
er 1
00 m
g.
J3010
Inje
ction
, fen
tan
yl citrate
, 0.1
mg
.
Co
ntra
cep
tion
CP
T/H
CP
CS
De
scriptio
nC
om
me
nts
Inse
rtion
, imp
lan
tab
le co
ntra
cep
tive ca
psu
les
Rem
ova
l, imp
lan
tab
le co
ntra
cep
tive ca
psu
les
Rem
ova
l with
rein
sertio
n, im
pla
nta
ble
con
trace
ptive
cap
sule
s
Inje
ction
, an
esth
etic a
gen
t, para
cervica
l (ute
rine) n
erve
Cervica
l cap
for co
ntra
cep
tive u
se
Mu
st have
HPH
C R
x Co
vera
ge to
have
p
rescrip
tion
con
trace
ptio
n co
vere
d in
fu
ll.
Perm
an
en
t imp
lan
tab
le co
ntra
cep
tive in
tratu
bal o
cclusio
n d
evice
(s) an
d d
elive
ry system
Inje
ction
, med
roxyp
rog
este
ron
e a
ceta
te, 1
mg
year d
ura
tion
ye
ar d
ura
tion
Intra
ute
rine co
pp
er co
ntra
cep
tive
Co
ntra
cep
tive su
pp
ly, ho
rmo
ne co
nta
inin
g p
atch
, each
Co
ntra
cep
tive su
pp
ly, ho
rmo
ne co
nta
inin
g va
gin
al rin
g, e
ach
Levo
no
rgestre
l (con
trace
ptive
) imp
lan
t system
, inclu
din
g im
pla
nts
an
d su
pp
lies (Im
pla
no
n)
Eto
no
gestre
l (con
trace
ptive
) imp
lan
t system
, inclu
din
g im
pla
nt a
nd
su
pp
lies
Inse
rtion
of le
von
og
estre
l -rele
asin
g in
trau
terin
e syste
m
im
pla
nts a
nd
sup
plie
s
Mu
st have
HPH
C R
x Co
vera
ge to
have
p
rescrip
tion
con
trace
ptio
n co
vere
d in
fu
ll.
Co
un
selin
g fo
r Ch
em
op
reven
tion
of B
reast C
an
cer
ICD
-9D
escrip
tion
Co
mm
en
ts
Fam
ily histo
ry of m
alig
nan
t neo
pla
sm o
f the b
reast
Co
vere
d w
hen
bille
d w
ith th
e liste
d
ICD
-9/1
0 d
x cod
es.
Fam
ily histo
ry of m
alig
nan
t neo
pla
sm o
f the o
vary
Ro
utin
e m
ed
ical e
xam
ME
MB
ER
CA
RE
—P
RO
TE
CT
ING
HE
ALT
H IN
FO
RM
AT
ION
Pa
tien
t Pro
tectio
n a
nd
Affo
rda
ble
Ca
re A
ct (con
t.)
(contin
ued)
Harva
rd P
ilgrim
Health
Care
—Pro
vider M
an
ual
B.2
8
Jan
uary 2
01
6
ICD
-10
De
scriptio
nC
om
me
nts
Fam
ily histo
ry of m
alig
nan
t neo
pla
sm o
f bre
ast
Fam
ily histo
ry of m
alig
nan
t neo
pla
sm o
f ova
ry
Z00.0
0En
cou
nte
r for g
en
era
l ad
ult m
ed
ical e
xam
inatio
n w
itho
ut a
bn
orm
al
find
ing
s
Co
un
selin
g to
Pre
ven
t To
bacco
Use
an
d T
ob
acco
-Cau
sed
Dise
ase
CP
T/H
CP
CS
De
scriptio
nC
om
me
nts
Smo
kin
g a
nd
tob
acco
use
cessa
tion
cou
nse
ling
visit; inte
rmed
iate
, g
reate
r than
3 m
inu
tes u
p to
10 m
inu
tes
Smo
kin
g a
nd
tob
acco
use
cessa
tion
cou
nse
ling
visit; inte
nsive
, gre
ate
r th
an
10 m
inu
tes
Smo
kin
g a
nd
tob
acco
cessa
tion
cou
nse
ling
visit for th
e a
symp
tom
atic
patie
nt; in
term
ed
iate
, gre
ate
r than
3 m
inu
tes, u
p to
10 m
inu
tes
Smo
kin
g a
nd
tob
acco
cessa
tion
cou
nse
ling
visit for th
e a
symp
tom
atic
patie
nt; in
term
ed
iate
, gre
ate
r than
10 m
inu
tes
Den
tal C
arie
s–Pre
ven
tion
of D
en
tal C
arie
s in P
resch
oo
l Ch
ildre
n
Co
din
gD
escrip
tion
Co
mm
en
ts
Pre
ven
tive visits a
nd
Eva
luatio
n &
Man
ag
em
en
t (EM
) service
s.A
ge 6
mo
nth
s thro
ug
h 1
1 ye
ars.
Fluo
ride V
arn
ish
Co
din
gD
escrip
tion
Co
mm
en
ts
Ap
plica
tion
of to
pica
l fluo
ride va
rnish
by a
ph
ysician
or o
ther q
uali-
fied
health
care
pro
fessio
nal
Dep
ressio
n–M
ajo
r Dep
ressiv
e D
isord
er in
Ch
ildre
n, A
do
lesce
nts a
nd
Ad
ults
ICD
-9D
escrip
tion
Co
mm
en
ts
Ro
utin
e m
ed
ical e
xam
Screen
ing
for d
ep
ressio
n, in
prim
ary
care
settin
gs, in
clud
es E
&M
visits an
d
Screen
ing
for d
ep
ressio
n
ICD
-10
De
scriptio
nC
om
me
nts
Z00.0
0En
cou
nte
r for g
en
era
l ad
ult m
ed
ical e
xam
inatio
n w
itho
ut a
bn
orm
al
find
ing
s
Screen
ing
for d
ep
ressio
n, in
prim
ary
care
settin
gs, in
clud
es E
&M
visits an
d
En
cou
nte
r for scre
en
ing
for o
ther d
isord
er
Dia
bete
s Mellitu
s Scre
en
ing
(Typ
e 2
Dia
bete
s)
ICD
-9D
escrip
tion
Co
mm
en
ts
Fam
hx-d
iab
ete
s mellitu
s
Ro
utin
e m
ed
ical e
xam
Screen
ing
exa
min
atio
n; d
iab
ete
s mellitu
s
ICD
-10
De
scriptio
nC
om
me
nts
Fam
ily histo
ry of d
iab
ete
s mellitu
s
Z00.0
0En
cou
nte
r for g
en
era
l ad
ult m
ed
ical e
xam
inatio
n w
itho
ut a
bn
orm
al
find
ing
s
Z13.1
En
cou
nte
r for scre
en
ing
for d
iab
ete
s mellitu
s
ME
MB
ER
CA
RE
—P
RO
TE
CT
ING
HE
ALT
H IN
FO
RM
AT
ION
Pa
tien
t Pro
tectio
n a
nd
Affo
rda
ble
Ca
re A
ct (con
t.)
(contin
ued)
Harva
rd P
ilgrim
Health
Care
—Pro
vider M
an
ual
B.2
9
Jan
uary 2
01
6
CP
T/H
CP
CS
De
scriptio
nC
om
me
nts
Glu
cose
; qu
an
titative
, blo
od
(exce
pt re
ag
en
t strip)
Co
vere
d w
hen
bille
d w
ith th
e liste
d
ICD
-9/1
0 d
x cod
es.
Glu
cose
; blo
od
, reag
en
t strip
Glu
cose
; po
st glu
cose
do
se (in
clud
es g
luco
se)
Glu
cose
; tole
ran
ce te
st (GTT), 3
specim
en
s (inclu
des g
luco
se)
Glu
cose
; tole
ran
ce te
st, each
ad
ditio
nal b
eyo
nd
3 sp
ecim
en
s
Hem
og
lob
in; g
lycosyla
ted
(A1C
)
Go
no
rrhea S
creen
ing
ICD
-9D
escrip
tion
Co
mm
en
ts
Ro
utin
e m
ed
ical e
xam
Fem
ale
ICD
-10
De
scriptio
nC
om
me
nts
Z00.0
0En
cou
nte
r for g
en
era
l ad
ult m
ed
ical e
xam
inatio
n w
itho
ut a
bn
orm
al
find
ing
s
Z11.3
En
cou
nte
r for scre
en
ing
for in
fectio
ns w
ith a
pre
do
min
an
tly sexu
al
mo
de o
f tran
smissio
nFe
male
CP
T/H
CP
CS
De
scriptio
nC
om
me
nts
go
no
rrho
eae, d
irect p
rob
e te
chn
iqu
e.
Co
vere
d w
hen
bille
d w
ith th
e liste
d
ICD
-9/1
0 d
x cod
es.
go
no
rrho
eae, a
mp
lified
pro
be te
chn
iqu
e.
go
no
rrho
eae, q
uan
tificatio
n.
Infe
ctiou
s ag
en
t an
tigen
dete
ction
by im
mu
no
assa
y with
dire
ct op
ti-ca
l ob
serva
tion
; Neisse
ria g
on
orrh
oeae.
Hep
atitis B
Viru
s Infe
ction
Scre
en
ing
–
CP
T/H
CP
CS
De
scriptio
nC
om
me
nts
Hep
atitis B
core
an
tibo
dy (H
BcA
B); T
ota
l
-
ven
tive, re
gard
less o
f dia
gn
osis.
Hep
atitis B
surfa
ce a
ntib
od
y (HB
sAb
).
-
niq
ue, q
ualita
tive o
r sem
iqu
an
titative
, mu
ltiple
step
meth
od
; hep
atitis
B su
rface
an
tigen
(HB
sAg
).
-
niq
ue, q
ualita
tive o
r sem
iqu
an
titative
, mu
ltiple
step
meth
od
; hep
atitis
viru
s, dire
ct pro
be te
chn
iqu
e.
viru
s, am
plifie
d p
rob
e te
chn
iqu
e.
viru
s, qu
an
tificatio
n.
Hig
h B
loo
d P
ressu
re S
creen
ing
De
scriptio
nC
om
me
nts
an
d o
ver (se
e co
mm
en
t). In
clud
ed
in th
e p
aym
en
t for a
pre
ven
-tive
care
visit.
ME
MB
ER
CA
RE
—P
RO
TE
CT
ING
HE
ALT
H IN
FO
RM
AT
ION
Pa
tien
t Pro
tectio
n a
nd
Affo
rda
ble
Ca
re A
ct (con
t.)
(contin
ued)
Harva
rd P
ilgrim
Health
Care
—Pro
vider M
an
ual
B.3
0
Jan
uary 2
01
6
Hu
man
Imm
un
od
eficie
ncy
Viru
s (HIV
)–Scre
en
ing
for A
do
lesce
nts a
nd
Ad
ults
CP
T/H
CP
CS
De
scriptio
nC
om
me
nts
-tive
service
wh
en
ap
pro
pria
tely co
ded
.
-
p
rob
e te
chn
iqu
e.
-fie
d p
rob
e te
chn
iqu
e.
qu
an
tificatio
n.
p
rob
e te
chn
iqu
e.
-fie
d p
rob
e te
chn
iqu
e.
-tive
service
wh
en
ap
pro
pria
tely co
ded
qu
an
tificatio
n.
tech
niq
ue, q
ualita
tive o
r sem
i-qu
an
titative
, mu
ltiple
-step
meth
od
,
tech
niq
ue, q
ualita
tive o
r sem
i-qu
an
titative
, mu
ltiple
-step
meth
od
,
Infe
ctiou
s ag
en
t an
tigen
dete
ction
by ra
pid
an
tibo
dy te
st of o
ral
Imm
un
izatio
n
afte
r all o
f the fo
llow
ing
con
ditio
ns a
re sa
tisfied
:
-
CP
T/
HC
PC
SD
escrip
tion
Co
mm
en
ts
ad
min
istratio
n, w
ith co
un
selin
g b
y ph
ysician
or o
ther q
ualifie
d h
ealth
care
Pre
ven
tive re
gard
less o
f dx.
ad
min
istratio
n, w
ith co
un
selin
g b
y ph
ysician
or o
ther q
ualifie
d h
ealth
care
ad
ditio
n to
cod
e fo
r prim
ary p
roce
du
re).
-
tan
eo
us, in
trad
erm
al, su
bcu
tan
eo
us, o
r intra
mu
scula
r inje
ction
s) wh
en
the
-
tan
eo
us, in
trad
erm
al, su
bcu
tan
eo
us, o
r intra
mu
scula
r inje
ction
s) wh
en
the
fo
r prim
ary p
roce
du
re).
ME
MB
ER
CA
RE
—P
RO
TE
CT
ING
HE
ALT
H IN
FO
RM
AT
ION
Pa
tien
t Pro
tectio
n a
nd
Affo
rda
ble
Ca
re A
ct (con
t.)
(contin
ued)
Harva
rd P
ilgrim
Health
Care
—Pro
vider M
an
ual
B.3
1
Jan
uary 2
01
6
CP
T/
HC
PC
SD
escrip
tion
Co
mm
en
ts
-n
asa
l or o
ral ro
ute
s of a
dm
inistra
tion
) wh
en
the p
hysicia
n co
un
sels th
e
p
er d
ay.
-n
asa
l or o
ral ro
ute
s of a
dm
inistra
tion
) wh
en
the p
hysicia
n co
un
sels th
e
pro
ced
ure
).
cou
nse
ling
wh
en
perfo
rmed
.
-
cuta
neo
us, o
r intra
mu
scula
r inje
ction
s); 1 va
ccine (sin
gle
or co
mb
inatio
n
-
tan
eo
us, o
r intra
mu
scula
r inje
ction
s); each
ad
ditio
nal va
ccine (sin
gle
or
-
mary p
roce
du
re).
to co
de fo
r prim
ary p
roce
du
re).
Hep
atitis A
vaccin
e, a
du
lt, for in
tram
uscu
lar u
se.
-m
uscu
lar u
se.
-m
uscu
lar u
se.
Hep
atitis A
an
d h
ep
atitis B
vaccin
e (H
ep
A-H
ep
B), a
du
lt do
sag
e, fo
r intra
-m
uscu
lar u
se.
fo
r intra
mu
scula
r use
.
on
ly, intra
mu
scula
r use
.
-
ule
), for in
tram
uscu
lar u
se.
for in
tram
uscu
lar u
se.
do
se sch
ed
ule
, for in
tram
uscu
lar u
se.
-
ule
, for in
tram
uscu
lar u
se.
ind
ividu
als 3
years a
nd
old
er, fo
r intra
mu
scula
r use
.
mo
nth
s of a
ge, fo
r intra
mu
scula
r use
.
years o
f ag
e a
nd
old
er, fo
r intra
mu
scula
r use
.
ME
MB
ER
CA
RE
—P
RO
TE
CT
ING
HE
ALT
H IN
FO
RM
AT
ION
Pa
tien
t Pro
tectio
n a
nd
Affo
rda
ble
Ca
re A
ct (con
t.)
(contin
ued)
Harva
rd P
ilgrim
Health
Care
—Pro
vider M
an
ual
B.3
2
Jan
uary 2
01
6
CP
T/
HC
PC
SD
escrip
tion
Co
mm
en
ts
an
d a
ntib
iotic fre
e, fo
r intra
mu
scula
r use
.
-n
icity via in
crease
d a
ntig
en
con
ten
t, for in
tram
uscu
lar u
se.
free, fo
r intra
mu
scula
r use
.
in
tram
uscu
lar u
se.
-la
r use
.
Pn
eu
mo
cocca
l con
jug
ate
vaccin
e, 1
3 va
len
t, for in
tram
uscu
lar u
se.
Ro
taviru
s vaccin
e, p
en
tava
len
t, 3 d
ose
sched
ule
, live, fo
r ora
l use
.
Ro
taviru
s vaccin
e, h
um
an
, atte
nu
ate
d, 2
do
se sch
ed
ule
, live, fo
r ora
l use
.
-
ye
ars o
f ag
e, fo
r intra
mu
scula
r use
.
-
in
tram
uscu
lar u
se.
intra
mu
scula
r use
.
-
Teta
nu
s toxo
id a
dso
rbed
, for in
tram
uscu
lar u
se.
Mu
mp
s virus va
ccine, live
, for su
bcu
tan
eo
us u
se.
Measle
s virus va
ccine, live
, for su
bcu
tan
eo
us u
se.
Ru
bella
virus va
ccine, live
, for su
bcu
tan
eo
us u
se.
Measle
s, mu
mp
s an
d ru
bella
virus va
ccine (M
MR
), live, fo
r sub
cuta
neo
us
use
.
Measle
s an
d ru
bella
virus va
ccine, live
, for su
bcu
tan
eo
us u
se.
-
neo
us u
se.
u
se.
Teta
nu
s an
d d
iph
theria
toxo
ids (T
c) ab
sorb
ed
, pre
serva
tive fre
e, w
hen
Teta
nu
s, dip
hth
eria
toxo
ids a
nd
ace
llula
r pertu
ssis vaccin
e (T
daP), w
hen
Teta
nu
s an
d d
iph
theria
toxo
ids (T
d) a
dso
rbed
wh
en
ad
min
istere
d to
ind
i-
ME
MB
ER
CA
RE
—P
RO
TE
CT
ING
HE
ALT
H IN
FO
RM
AT
ION
Pa
tien
t Pro
tectio
n a
nd
Affo
rda
ble
Ca
re A
ct (con
t.)
(contin
ued)
Harva
rd P
ilgrim
Health
Care
—Pro
vider M
an
ual
B.3
3
Jan
uary 2
01
6
CP
T/
HC
PC
SD
escrip
tion
Co
mm
en
ts
-
-
Pn
eu
mo
cocca
l po
lysacch
arid
e va
ccine, 2
3-va
len
t, ad
ult o
r imm
un
osu
p-
pre
ssed
patie
nt d
osa
ge, w
hen
ad
min
istere
d to
ind
ividu
als 2
years o
r old
er,
for su
bcu
tan
eo
us o
r intra
mu
scula
r use
.
M
en
ing
oco
ccal p
olysa
ccharid
e va
ccine (a
ny g
rou
p(s)), fo
r sub
cuta
neo
us
use
.
-
len
t), for in
tram
uscu
lar u
se.
Zo
ster (sh
ing
les) va
ccine, live
, for su
bcu
tan
eo
us in
jectio
n N
ote
: cove
rag
e
Hep
atitis B
vaccin
e, d
ialysis o
r imm
un
osu
pp
resse
d p
atie
nt d
osa
ge (3
do
se
sched
ule
), for in
tram
uscu
lar u
se.
Hep
atitis B
vaccin
e, a
do
lesce
nt (2
do
se sch
ed
ule
), for in
tram
uscu
lar u
se.
in
tram
uscu
lar u
se.
Hep
atitis B
vaccin
e, a
du
lt do
sag
e, fo
r intra
mu
scula
r use
.
sched
ule
), for in
tram
uscu
lar u
se.
-
cula
r use
.
Ad
min
istratio
n o
f pn
eu
mo
cocca
l vaccin
e.
G0010
Ad
min
istratio
n o
f Hep
atitis B
.
Lun
g S
creen
ing
CP
T/H
CP
CS
De
scriptio
nC
om
me
nts
Co
mp
ute
d to
mo
gra
ph
y, tho
rax; w
itho
ut co
ntra
st mate
rial.
Co
vere
d w
hen
bille
d w
ith th
e fo
llow
-in
g IC
D-9
dia
gn
ose
s:
-
nan
t neo
pla
sm
co
nd
ition
Co
vere
d w
hen
bille
d w
ith th
e fo
llow
-in
g IC
D-1
0 d
iag
no
ses:
Z12.2
— E
nco
un
ter fo
r screen
ing
for
malig
nan
t neo
pla
sm o
f resp
irato
ry o
rgan
s
-
tine d
ep
en
den
ce
u
nsp
ecifie
d
ME
MB
ER
CA
RE
—P
RO
TE
CT
ING
HE
ALT
H IN
FO
RM
AT
ION
Pa
tien
t Pro
tectio
n a
nd
Affo
rda
ble
Ca
re A
ct (con
t.)
(contin
ued)
Harva
rd P
ilgrim
Health
Care
—Pro
vider M
an
ual
B.3
4
Jan
uary 2
01
6
Mam
mo
gra
ph
y S
creen
ing
CP
T/H
CP
CS
De
scriptio
nC
om
me
nts
Co
mp
ute
r aid
ed
dete
ction
(com
pu
ter a
lgo
rithm
an
alysis o
f dig
ital
imag
e d
ata
for le
sion
dete
ction
) with
furth
er p
hysicia
n re
view
for
imag
es; scre
en
ing
mam
mo
gra
ph
y (List sep
ara
tely in
ad
ditio
n to
cod
e
for p
rimary p
roce
du
re).
Screen
ing
ind
icate
d in
pro
ced
ure
co
de: n
ot b
y dia
gn
osis o
r freq
uen
cy.Scre
en
ing
mam
mo
gra
ph
y, bila
tera
l (two
view
film stu
dy o
f each
b
reast).
G0202
Screen
ing
mam
mo
gra
ph
y pro
du
cing
dire
ct dig
ital im
ag
e, b
ilate
ral, a
ll vie
ws.
New
bo
rn S
creen
ing
s
Hearin
g Scre
en
ing
ICD
-9D
escrip
tion
Co
mm
en
ts
En
cou
nte
r for h
ealth
sup
ervisio
n a
nd
care
of fo
un
dlin
g
re
gard
less o
f dx, p
rimary.
re
gard
less o
f dx, p
rimary.
Care
of h
ealth
y child
nec
Ro
utin
e in
fan
t or ch
ild h
ealth
check
Ro
utin
e m
ed
ical e
xam
En
cou
nte
r for h
earin
g e
xam
inatio
n fo
llow
ing
faile
d h
earin
g scre
en
ing
ICD
-10
De
scriptio
nC
om
me
nts
En
cou
nte
r for h
ealth
sup
ervisio
n a
nd
care
of fo
un
dlin
g
En
cou
nte
r for h
ealth
sup
ervisio
n a
nd
care
of o
ther h
ealth
y infa
nt a
nd
ch
ild
Z00.1
21
En
cou
nte
r for ro
utin
e ch
ild h
ealth
exa
min
atio
n w
ith a
bn
orm
al
find
ing
s
En
cou
nte
r for ro
utin
e ch
ild h
ealth
exa
min
atio
n w
itho
ut a
bn
orm
al
find
ing
s
Z01.1
10
En
cou
nte
r for h
earin
g e
xam
inatio
n fo
llow
ing
faile
d h
earin
g scre
en
ing
Z00.0
0En
cou
nte
r for g
en
era
l ad
ult m
ed
ical e
xam
inatio
n w
itho
ut a
bn
orm
al
find
ing
s
CP
T/H
CP
CS
De
scriptio
nC
om
me
nts
Screen
ing
Test, p
ure
ton
e, a
ir on
ly (Also
paya
ble
un
der p
reve
ntive
b
en
efit fo
r child
ren
an
d a
du
lts as p
er th
e C
ertifica
te o
f Co
vera
ge).
Co
vere
d w
hen
bille
d w
ith th
e liste
d
ICD
-9/1
0 d
x cod
es.
testin
g o
f the ce
ntra
l nervo
us syste
m; co
mp
reh
en
sive.
testin
g o
f the ce
ntra
l nervo
us syste
m; lim
ited
.
Evo
ked
oto
aco
ustic e
missio
ns; lim
ited
(sing
le stim
ulu
s leve
l, eith
er
tran
sien
t or d
istortio
n p
rod
ucts).
Evo
ked
oto
aco
ustic e
missio
ns; co
mp
reh
en
sive o
r dia
gn
ostic e
valu
atio
n
-
sion
s at m
ultip
le le
vels a
nd
freq
uen
cies).
Hearin
g scre
en
ing
.
Hyp
oth
yroid
ism Scre
en
ing
CP
T/H
CP
CS
De
scriptio
nC
om
me
nts
Th
yroxin
e; re
qu
iring
elu
tion
(e.g
., neo
nata
l).C
ove
red
wh
en
bille
d w
ith a
pre
ven
tive
(dx co
de).
Th
yroid
stimu
latin
g h
orm
on
e
ME
MB
ER
CA
RE
—P
RO
TE
CT
ING
HE
ALT
H IN
FO
RM
AT
ION
Pa
tien
t Pro
tectio
n a
nd
Affo
rda
ble
Ca
re A
ct (con
t.)
(contin
ued)
Harva
rd P
ilgrim
Health
Care
—Pro
vider M
an
ual
B.3
5
Jan
uary 2
01
6
Ph
en
ylketo
nu
ria Scre
en
ing
CP
T/H
CP
CS
De
scriptio
nC
om
me
nts
Co
vere
d w
hen
bille
d w
ith a
pre
ven
tive
(dx co
de).
Th
yroid
stimu
latin
g h
orm
on
e (T
SH)
Sickle
Cell Scre
en
ing
ICD
-9D
escrip
tion
Co
mm
en
ts
Ro
utin
e m
ed
ical e
xam
Screen
ing
exa
min
atio
n; sick
le-ce
ll dise
ase
or tra
it
ICD
-10
De
scriptio
nC
om
me
nts
Z00.0
0En
cou
nte
r for g
en
era
l ad
ult m
ed
ical e
xam
inatio
n w
itho
ut a
bn
orm
al
find
ing
s
Z13.0
En
cou
nte
r for scre
en
ing
for d
isease
s of th
e b
loo
d a
nd
blo
od
-form
ing
o
rgan
s an
d ce
rtain
diso
rders in
volvin
g th
e im
mu
ne m
ech
an
ism
CP
T/H
CP
CS
De
scriptio
nC
om
me
nts
Hem
og
lob
in fra
ction
atio
n a
nd
qu
an
titatio
n; e
lectro
ph
ore
sis (e.g
., A2,
IC
D-9
/10 d
x cod
es.
Hem
og
lob
in fra
ction
atio
n a
nd
qu
an
titatio
n; ch
rom
ato
gra
ph
y (e.g
.,
Hem
og
lob
in; F (fe
tal), ch
em
ical
Hem
og
lob
in; F (fe
tal), q
ualita
tive
Hem
og
lob
in; p
lasm
a
Sickle
cell scre
en
Ob
esity
Scre
en
ing
for C
hild
ren
, Ad
ole
scen
ts an
d A
du
lts
ICD
-9D
escrip
tion
Co
mm
en
ts
Ro
utin
e in
fan
t or ch
ild h
ealth
check
Ro
utin
e m
ed
ical e
xam
Screen
ing
exa
min
atio
n; o
besity
ICD
-10
De
scriptio
nC
om
me
nts
En
cou
nte
r for ro
utin
e ch
ild h
ea
lth e
xam
ina
tion
with
ou
t a
bn
orm
al fin
din
gs
Z0
0.0
0E
nco
un
ter fo
r ge
ne
ral a
du
lt me
dica
l exa
min
atio
n w
itho
ut
ab
no
rma
l find
ing
s
En
cou
nte
r for scre
en
ing
for o
the
r diso
rde
r
CP
T/H
CP
CS
De
scriptio
nC
om
me
nts
Med
ical n
utritio
nal co
un
selin
gC
ove
red
wh
en
bille
d w
ith a
n E
&M
se
rvice a
nd
bille
d w
ith th
e liste
d
ICD
-9/1
0 d
x cod
es.
Oste
op
oro
sis Scre
en
ing
ICD
-9D
escrip
tion
Co
mm
en
ts
Fam
ily histo
ry of o
steo
po
rosis
Ro
utin
e m
ed
ical e
xam
Specia
l screen
ing
for o
steo
po
rosis
ME
MB
ER
CA
RE
—P
RO
TE
CT
ING
HE
ALT
H IN
FO
RM
AT
ION
Pa
tien
t Pro
tectio
n a
nd
Affo
rda
ble
Ca
re A
ct (con
t.)
(contin
ued)
Harva
rd P
ilgrim
Health
Care
—Pro
vider M
an
ual
B.3
6
Jan
uary 2
01
6
ICD
-10
De
scriptio
nC
om
me
nts
Fam
ily histo
ry of o
steo
po
rosis
Z00.0
0En
cou
nte
r for g
en
era
l ad
ult m
ed
ical e
xam
inatio
n w
itho
ut a
bn
orm
al
find
ing
s
En
cou
nte
r for scre
en
ing
for o
steo
po
rosis
CP
T/H
CP
CS
De
scriptio
nC
om
me
nts
Ultra
sou
nd
bo
ne d
en
sity measu
rem
en
t an
d in
terp
reta
tion
, perip
hera
l site
(s), an
y meth
od
.
Co
vere
d w
hen
bille
d w
ith th
e liste
d
ICD
-9/1
0 d
x cod
es.
m
ore
sites; a
xial sk
ele
ton
(e.g
., hip
s, pelvis, sp
ine).
m
ore
sites; a
pp
en
dicu
lar sk
ele
ton
(perip
hera
l) (e.g
., rad
ius, w
rist, heel).
G0130
mo
re site
s; ap
pen
dicu
lar sk
ele
ton
(perip
hera
l) (e.g
., rad
ius, w
rist, heel).
Ph
arm
acy
— U
.S. P
reven
tive S
erv
ices T
ask
Force
A &
B R
eco
mm
en
datio
n M
ed
icatio
ns
Harva
rd P
ilgrim
Health
Care
has in
clud
ed
certa
in ca
teg
orie
s of m
ed
icatio
ns in
the p
reve
ntive
service
s cove
rag
e b
ase
d
on
reco
mm
en
datio
ns fro
m th
e U
.S. Pre
ven
tive Se
rvices T
ask
Force
. Th
ese
pre
ven
tive m
ed
icatio
ns a
re co
vere
d u
nd
er th
e
Patie
nt P
rote
ction
an
d A
fford
ab
le C
are
Act a
t no
cost ($
0 co
paym
en
t) to m
em
bers w
hen
pre
scribed
by a
licen
sed
pro
-vid
er a
nd
filled
at a
netw
ork
ph
arm
acy. C
ove
rag
e lim
itatio
ns su
ch a
s ag
e a
nd
gen
der ru
les a
pp
ly, see Sp
ecia
l Co
vera
ge
C
on
sidera
tion
s (in ta
ble
) for d
eta
ils belo
w. T
his co
vera
ge d
oes n
ot a
pp
ly to m
em
bers o
f “g
ran
dfa
there
d” p
lan
s.
No
te: P
reve
ntive
ove
r-the-co
un
ter (O
TC
) med
icatio
ns a
re co
vere
d in
full w
hen
pre
scribed
by a
licen
sed
pro
vider a
nd
dis-
pen
sed
at a
ph
arm
acy p
ursu
an
t to a
pre
scriptio
n.
Me
dica
tion
Ap
plie
s to:
Sp
ecia
l Co
ve
rag
e C
on
side
ratio
ns
Asp
irinO
TC
gen
eric o
nly
Fluo
ride d
rop
s & ta
ble
ts R
x bra
nd
s an
d g
en
erics
Co
vere
d in
full fo
r pre
scho
ol ch
ildre
n a
ge 6
mo
nth
s
Pre
scriptio
n sm
okin
g ce
ssatio
n p
rod
ucts
Rx b
ran
ds a
nd
gen
erics
Co
vere
d in
full. Q
uan
tity limita
tion
s may a
pp
ly.
O
TC
bra
nd
s an
d g
en
erics
Bre
ast ca
nce
r med
icatio
ns
Rx b
ran
ds a
nd
gen
erics
Co
vere
d in
full fo
r mem
ber w
ho
are
at in
crease
d risk
fo
r bre
ast ca
nce
r an
d a
t low
risk fo
r ad
verse
med
ica-
tion
effe
cts.
p
roce
du
reR
x on
ly
p
rep
kits a
re n
ot co
vere
d.
Rh
Inco
mp
atib
ility S
creen
ing
—
CP
T/H
CP
CS
De
scriptio
nC
om
me
nts
Co
vere
d w
ith d
iag
no
sis of p
reg
nan
cy.O
bste
tric pan
el
Ro
utin
e In
fan
t or C
hild
Health
Ch
eck
ICD
-9D
escrip
tion
Co
mm
en
ts
Ro
utin
e in
fan
t or ch
ild h
ealth
check
Ro
utin
e m
ed
ical e
xam
ICD
-10
De
scriptio
nC
om
me
nts
En
cou
nte
r for ro
utin
e ch
ild h
ealth
exa
min
atio
n w
itho
ut a
bn
orm
al
find
ing
s
Z00.0
0En
cou
nte
r for g
en
era
l ad
ult m
ed
ical e
xam
inatio
n w
itho
ut a
bn
orm
al
find
ing
s
ME
MB
ER
CA
RE
—P
RO
TE
CT
ING
HE
ALT
H IN
FO
RM
AT
ION
Pa
tien
t Pro
tectio
n a
nd
Affo
rda
ble
Ca
re A
ct (con
t.)
(contin
ued)
Harva
rd P
ilgrim
Health
Care
—Pro
vider M
an
ual
B.3
7
Jan
uary 2
01
6
ICD
-9D
escrip
tion
Co
mm
en
ts
Ro
utin
e in
fan
t or ch
ild h
ealth
check
Ro
utin
e m
ed
ical e
xam
ICD
-10
De
scriptio
nC
om
me
nts
En
cou
nte
r for ro
utin
e ch
ild h
ealth
exa
min
atio
n w
itho
ut a
bn
orm
al
find
ing
s
Z00.0
0En
cou
nte
r for g
en
era
l ad
ult m
ed
ical e
xam
inatio
n w
itho
ut a
bn
orm
al
find
ing
s
CP
T/H
CP
CS
De
scriptio
nC
om
me
nts
Early La
ng
uag
e M
ilesto
ne Scre
en
), with
inte
rpre
tatio
n a
nd
rep
ort.
Prim
ary ca
re se
tting
, pre
ven
tive w
ith
the liste
d IC
D-9
/10 d
x cod
es.
Lead
Screen
ing
ICD
-9D
escrip
tion
Co
mm
en
ts
Ro
utin
e in
fan
t or ch
ild h
ealth
check
Perso
nal h
istory o
f con
tact w
ith a
nd
(susp
ecte
d) e
xpo
sure
to le
ad
Hig
h risk
child
ren
.
Ro
utin
e m
ed
ical e
xam
Screen
-con
tam
inatio
n N
EC
ICD
-10
De
scriptio
nC
om
me
nts
En
cou
nte
r for ro
utin
e ch
ild h
ealth
exa
min
atio
n w
itho
ut a
bn
orm
al
find
ing
s
Co
nta
ct with
an
d (su
specte
d) e
xpo
sure
to le
ad
Hig
h risk
child
ren
.
Z00.0
0En
cou
nte
r for g
en
era
l ad
ult m
ed
ical e
xam
inatio
n w
itho
ut a
bn
orm
al
find
ing
s
En
cou
nte
r for scre
en
ing
for d
isord
er d
ue to
exp
osu
re to
con
tam
inan
ts
CP
T/H
CP
CS
De
scriptio
nC
om
me
nts
Lead
Hig
h risk
child
ren
.
Tu
bercu
lin T
est
ICD
-9D
escrip
tion
Co
mm
en
ts
Ro
utin
e in
fan
t or ch
ild h
ealth
check
Ro
utin
e m
ed
ical e
xam
Screen
ing
exa
min
atio
n fo
r pu
lmo
nary tu
bercu
losis
Hig
h risk
child
ren
.
ICD
-10
De
scriptio
nC
om
me
nts
En
cou
nte
r for h
ealth
sup
ervisio
n a
nd
care
of fo
un
dlin
g
En
cou
nte
r for h
ealth
sup
ervisio
n a
nd
care
of o
ther h
ealth
y infa
nt a
nd
ch
ild
En
cou
nte
r for ro
utin
e ch
ild h
ealth
exa
min
atio
n w
itho
ut a
bn
orm
al
find
ing
sH
igh
risk ch
ildre
n.
CP
T/H
CP
CS
De
scriptio
nC
om
me
nts
Lead
Ch
ildre
n a
t risk.
ME
MB
ER
CA
RE
—P
RO
TE
CT
ING
HE
ALT
H IN
FO
RM
AT
ION
Pa
tien
t Pro
tectio
n a
nd
Affo
rda
ble
Ca
re A
ct (con
t.)
(contin
ued)
Harva
rd P
ilgrim
Health
Care
—Pro
vider M
an
ual
B.3
8
Jan
uary 2
01
6
ICD
-9D
escrip
tion
Co
mm
en
ts
Ro
utin
e in
fan
t or ch
ild h
ealth
check
Ro
utin
e m
ed
ical e
xam
ICD
-10
De
scriptio
nC
om
me
nts
En
cou
nte
r for h
ealth
sup
ervisio
n a
nd
care
of fo
un
dlin
g
En
cou
nte
r for h
ealth
sup
ervisio
n a
nd
care
of o
ther h
ealth
y infa
nt a
nd
ch
ild
En
cou
nte
r for ro
utin
e ch
ild h
ealth
exa
min
atio
n w
itho
ut a
bn
orm
al
find
ing
s
CP
T/H
CP
CS
De
scriptio
nC
om
me
nts
Prim
ary ca
re se
tting
s, no
t specia
lists visits a
nd
is no
t un
der ro
utin
e a
nn
ual
eye
exa
m.
Screen
ing
test o
f visual a
cuity, q
uan
titative
, bila
tera
l
Ru
bella
Scre
en
ing
by H
istory
of V
accin
atio
n o
r by S
ero
log
y
ICD
-9D
escrip
tion
Co
mm
en
ts
Ro
utin
e m
ed
ical e
xam
Fem
ale
Screen
ing
exa
min
atio
n fo
r rub
ella
ICD
-10
De
scriptio
nC
om
me
nts
En
cou
nte
r for ro
utin
e ch
ild h
ealth
exa
min
atio
n w
itho
ut a
bn
orm
al
find
ing
sFe
male
En
cou
nte
r for scre
en
ing
for o
ther vira
l dise
ase
sFe
male
CP
T/H
CP
CS
De
scriptio
nC
om
me
nts
An
tibo
dy; ru
bella
IC
D-9
/10 d
x cod
es.
Syp
hilis S
creen
ing
– Th
e fo
llow
ing
is covere
d w
hen
bille
d w
ith a
dia
gn
osis fo
r pre
gn
an
cy o
r screen
ing
for ve
nere
al d
isease
s
ICD
-9D
escrip
tion
Co
mm
en
ts
Ro
utin
e m
ed
ical e
xam
tra
nsm
itted
dise
ase
s
Screen
ing
for se
xually tra
nsm
itted
dise
ase
s NO
S
Exclu
des: Sp
ecia
l screen
ing
for n
on
-b
acte
rial se
xually tra
nsm
itted
dise
ase
s
Un
specifie
d b
acte
rial a
nd
spiro
cheta
l dise
ase
ICD
-10
De
scriptio
nC
om
me
nts
En
cou
nte
r for su
pervisio
n o
f no
rmal first p
reg
nan
cy, un
specifie
d tri-
meste
r
En
cou
nte
r for su
pervisio
n o
f oth
er n
orm
al p
reg
nan
cy, un
specifie
d
trimeste
r
Exclu
des: Sp
ecia
l screen
ing
for n
on
-b
acte
rial se
xually tra
nsm
itted
dise
ase
s
Z33.1
Pre
gn
an
t State
, incid
en
tal
Sup
ervisio
n o
f pre
gn
an
cy with
histo
ry of in
fertility, u
nsp
ecifie
d tri-
meste
r
Sup
ervisio
n o
f pre
gn
an
cy with
histo
ry of e
ctop
ic or m
ola
r pre
gn
an
cy, u
nsp
ecifie
d trim
este
r
Sup
ervisio
n o
f pre
gn
an
cy with
oth
er p
oo
r rep
rod
uctive
or o
bste
tric h
istory, first trim
este
r
ME
MB
ER
CA
RE
—P
RO
TE
CT
ING
HE
ALT
H IN
FO
RM
AT
ION
Pa
tien
t Pro
tectio
n a
nd
Affo
rda
ble
Ca
re A
ct (con
t.)
(contin
ued)
Harva
rd P
ilgrim
Health
Care
—Pro
vider M
an
ual
B.3
9
Jan
uary 2
01
6
ICD
-10
De
scriptio
nC
om
me
nts
Sup
ervisio
n o
f pre
gn
an
cy with
gra
nd
mu
ltiparity, u
nsp
ecifie
d
trimeste
r
Sup
ervisio
n o
f pre
gn
an
cy with
histo
ry of p
re-te
rm la
bo
r, first trim
este
r
Sup
ervisio
n o
f pre
gn
an
cy with
histo
ry of e
ctop
ic or m
ola
r pre
gn
an
cy, u
nsp
ecifie
d trim
este
r
Sup
ervisio
n o
f pre
gn
an
cy with
oth
er p
oo
r rep
rod
uctive
or o
bste
tric h
istory, first trim
este
r
Sup
ervisio
n o
f pre
gn
an
cy with
insu
fficien
t an
ten
ata
l care
, un
specifie
d
trimeste
r
Sup
ervisio
n o
f eld
erly p
rimig
ravid
a, u
nsp
ecifie
d trim
este
r
Sup
ervisio
n o
f eld
erly m
ultig
ravid
a, u
nsp
ecifie
d trim
este
r
Sup
ervisio
n o
f you
ng
prim
igra
vida, u
nsp
ecifie
d trim
este
r
Sup
ervisio
n o
f you
ng
mu
ltigra
vida, u
nsp
ecifie
d trim
este
r
Sup
ervisio
n o
f pre
gn
an
cy resu
lting
from
assiste
d re
pro
du
ctive te
ch-
no
log
y, un
specifie
d trim
este
r
Sup
ervisio
n o
f pre
gn
an
cy with
histo
ry of in
ute
ro p
roce
du
re d
urin
g
pre
viou
s pre
gn
an
cy, un
specifie
d trim
este
r
Pre
gn
an
cy with
inco
nclu
sive fe
tal via
bility, n
ot a
pp
licab
le o
r u
nsp
ecifie
d
Sup
ervisio
n o
f oth
er h
igh
risk p
reg
nan
cies, u
nsp
ecifie
d trim
este
r
Sup
ervisio
n o
f hig
h risk
pre
gn
an
cy, un
specifie
d, u
nsp
ecifie
d trim
este
r
Z00.0
0En
cou
nte
r for g
en
era
l ad
ult m
ed
ical e
xam
inatio
n w
itho
ut a
bn
orm
al
find
ing
s
En
cou
nte
r for g
yneco
log
ical e
xam
inatio
n (g
en
era
l) (rou
tine) w
ith
ab
no
rmal fin
din
gs
En
cou
nte
r for g
yneco
log
ical e
xam
inatio
n (g
en
era
l) (rou
tine) w
itho
ut
ab
no
rmal fin
din
gs
Z11.2
En
cou
nte
r for scre
en
ing
for o
ther b
acte
rial d
isease
s
Z11.3
En
cou
nte
r for scre
en
ing
for in
fectio
ns w
ith a
pre
do
min
an
tly sexu
al
mo
de o
f tran
smissio
n
En
cou
nte
r for scre
en
ing
for o
ther in
fectio
us a
nd
para
sitic dise
ase
s
En
cou
nte
r for scre
en
ing
for o
ther in
fectio
us a
nd
para
sitic dise
ase
s
CP
T/H
CP
CS
De
scriptio
nC
om
me
nts
AR
T)
Co
vere
d w
hen
bille
d w
ith th
e liste
d
ICD
-9/1
0 d
x cod
es.
Syph
ilis test, n
on
-trep
on
em
al a
ntib
od
y; qu
an
titative
Vo
lun
tary
Ste
rilizatio
n
CP
T/H
CP
CS
De
scriptio
nC
om
me
nts
Ph
arm
acy
Co
vere
d w
hen
bille
d w
ith
Ph
arm
acy So
lutio
ns
Ph
arm
acy-O
ther
Med
ical Su
pp
lies
An
esth
esia
Reco
very R
oo
mC
ove
red
wh
en
bille
d w
ith
An
esth
esia
-tub
al lig
atio
n
ME
MB
ER
CA
RE
—P
RO
TE
CT
ING
HE
ALT
H IN
FO
RM
AT
ION
Pa
tien
t Pro
tectio
n a
nd
Affo
rda
ble
Ca
re A
ct (con
t.)
(contin
ued)
Harva
rd P
ilgrim
Health
Care
—Pro
vider M
an
ual
B.4
0
Jan
uary 2
01
6
CP
T/H
CP
CS
De
scriptio
nC
om
me
nts
Hyste
rosco
py, su
rgica
l; with
bila
tera
l fallo
pia
n tu
be ca
nn
ula
tion
to
ind
uce
occlu
sion
by p
lace
men
t of p
erm
an
en
t imp
lan
ts
Ap
plie
s to fe
male
on
ly.
Ligatio
n o
r tran
sectio
n o
f fallo
pia
n tu
be(s), a
bd
om
inal o
r vag
inal
ap
pro
ach
, un
ilate
ral o
r bila
tera
l
Ligatio
n o
r tran
sectio
n o
f fallo
pia
n tu
be(s), a
bd
om
inal o
r vag
inal
-
tion
(sep
ara
te p
roce
du
re)
Ligatio
n o
r tran
sectio
n o
f fallo
pia
n tu
be(s) w
hen
do
ne a
t the tim
e o
f ce
sare
an
delive
ry or in
tra-a
bd
om
inal su
rgery (n
ot a
sep
ara
te p
roce
-d
ure
) (List sep
ara
tely in
ad
ditio
n to
cod
e fo
r prim
ary p
roce
du
re)
Occlu
sion
of fa
llop
ian
tub
e(s) b
y device
(eg
, ban
d, clip
, Falo
pe rin
g)
vag
inal o
r sup
rap
ub
ic ap
pro
ach
Lap
aro
scop
y, surg
ical; w
ith fu
lgu
ratio
n o
f ovid
ucts (w
ith o
r with
ou
t tra
nse
ction
)
Lap
aro
scop
y, surg
ical; w
ith o
cclusio
n o
f ovid
ucts b
y device
(eg
, ban
d,
clip, o
r Falo
pe rin
g)
Salp
ing
ecto
my, co
mp
lete
or p
artia
l, un
ilate
ral o
r bila
tera
l (sep
ara
te
pro
ced
ure
)
Co
vere
d w
hen
bille
d w
ith
Inje
ction
, hep
arin
sod
ium
, per 1
000 u
nits
Inje
ction
, mo
rph
ine su
lfate
, up
to 1
0 m
g
Inje
ction
, on
dan
setro
n H
Cl, p
er 1
mg
Rin
gers la
ctate
infu
sion
, up
to 1
,000 cc
J3010
Inje
ction
, fen
tan
yl citrate
, 0.1
mg
Inje
ction
, meto
clop
ram
ide H
Cl, u
p to
10 m
g
J0330
Inje
ction
, succin
ylcho
line ch
lorid
e, u
p to
20 m
g
J1100
Inje
ction
, dexa
meth
aso
ne so
diu
m p
ho
sph
ate
, 1 m
g
J1630
Inje
ction
, dro
perid
ol a
nd
fen
tan
yl citrate
, up
to 2
ml a
mp
ule
J2001
Inje
ction
, lido
cain
e H
Cl fo
r intra
ven
ou
s infu
sion
, 10 m
g
No
rmal Sa
line So
lutio
n
Welln
ess E
xam
inatio
ns
De
scriptio
nC
om
me
nts
Well b
ab
y, well ch
ild, w
ell a
du
lt, well w
om
an
Re
sou
rces
Fed
era
l Health
Care
Refo
rm
ME
MB
ER
CA
RE
—P
RO
TE
CT
ING
HE
ALT
H IN
FO
RM
AT
ION
Pa
tien
t Pro
tectio
n a
nd
Affo
rda
ble
Ca
re A
ct (con
t.)
(contin
ued)
Harva
rd P
ilgrim
Health
Care
—Pro
vider M
an
ual
B.4
1
Jan
uary 2
01
6
se
rvices to
cod
ing
grid
d
iab
ete
s screen
ing
ME
MB
ER
CA
RE
—P
RO
TE
CT
ING
HE
ALT
H IN
FO
RM
AT
ION
Pa
tien
t Pro
tectio
n a
nd
Affo
rda
ble
Ca
re A
ct (con
t.)
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