This quick guide from Prevounce provides brief background information on the Affordable Care Act (ACA) and then identifies ACA preventive services and the CPT codes that correspond with each service. Along with the CPT codes, the guide identifies patient eligibility for each service. When listing all associated CPT codes would be impractical for a guide of this nature, we have provided a link to a webpage that provides the CPT codes you should use.
We hope you find this guide to be a helpful resource when coding and billing for preventive services. If you are looking for coding and billing support, we invite you to learn about Prevounce and what our platform can do for your practice by scheduling a demo.
Background on ACA and Preventive Services
On March 23, 2010 the ACA took effect and drastically expanded access to preventive services for millions of Americans. The ACA placed mandates on all non-grandfathered health plans requiring them to provide preventive services coverage for their members. In addition, when these preventive services are conducted at their proper intervals and performed by an in-network practitioner, they must be provided to patients for free (i.e., no out-of-pocket expense), regardless of copayment, coinsurance, or deductible, as long as the services are rendered by network providers.
While the added preventive services may have been a tough pill for some payers to initially swallow, it is now widely accepted that increased access to preventive services actually represents significant cost savings for insurers and the healthcare system as a whole. Chronic disease is the leading driver in the United States’ over $3.5 trillion in healthcare costs and the most effective way to avoid, treat and mitigate chronic conditions is through proactive preventive services. Since ACA continues to expand preventive service coverage so widely, practitioners have the opportunity to positively impact the health and wellbeing of nearly every American with the goal of lowering the prevalence of chronic disease and illness throughout our country for years to come.
What preventive services are covered under the ACA?
Below is a list of ACA preventive services and their CPT codes and descriptions as well as patient eligibility. This list is not static, as services may be added as the U.S. Preventive Task Force continues to review medical research and make suggestions for further service coverage.
Note: In some instances, codes provided are technically HCPCS codes, but we have labeled all codes as CPT for readability.
Abdominal aortic aneurysm screening
- CPT G0389 — Ultrasound b-scan and/or real time with image documentation; for abdominal aortic aneurysm (aaa) screening
- Eligibility: Men aged 65 to 75 who previously or currently smoke. This screening is covered once per lifetime.
Alcohol misuse screening and counseling
- CPT G0442 — Annual alcohol misuse screening, 15 minutes
- CPT G0443 — Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes
- Eligibility: All patients are eligible for an annual screening, with four additional brief face-face counseling sessions per year for patients who screen positive for alcohol misuse.
- CPT G8598 — Aspirin or another antiplatelet therapy used
- Eligibility: Aspirin is used in high cardiovascular risk adults aged 50 to 59 to prevent cardiovascular disease and colorectal cancer.
Blood pressure screening, cardiovascular disease screening, cholesterol screening and statin preventive medications
- CPT 80061 — Lipid panel (must include CPT 82465 cholesterol, serum total; CPT 83718 lipoprotein, direct measurement, high density cholesterol; and CPT 84478 triglycerides)
- Eligibility: Adults of higher cardiovascular risk. Medicare specifically covers a cholesterol screening once every 5 years and, in addition to cholesterol screening, the services also include testing for lipid and triglyceride levels. All patients are eligible to receive blood pressure screenings.
Colorectal cancer screening
- CPT — A list of CPT codes with descriptions and patient qualifiers can be found here.
- Eligibility: Specifically, for Medicare patients, colorectal cancer screening can be performed in a few different ways with each having its own qualifiers based on risk.
- For screenings using the multitarget sDNA test, patients must be between the ages of 50 and 85, be asymptomatic, and at an average risk of developing colorectal cancer. Patients are eligible for this screening once every three years.
- Screening flexible sigmoidoscopy: Once every 48 months
- Colonoscopy: Once ever 10 years or 48 months after a previous sigmoidoscopy. For high-risk patients, colonoscopy is covered once ever 24 months.
- Fecal occult blood tests (FOBTs): Once every 12 months
- Screening barium enemas: Once every 12 months
- CPT G0444 — Annual depression screening, 15 minutes
- Eligibility: ACA mandated that insurance plans must cover a screening for depression. For Medicare beneficiaries, depression screening is covered once annually.
- CPT 82947 - Glucose; quantitative, blood (except reagent strip)
- CPT 82950 - Glucose; post glucose dose (includes glucose)
- CPT 82951 - Glucose; tolerance test (GTT), 3 specimens (includes glucose)
- Eligibility: This screening is for patients with certain diabetes risk factors or a diagnosis of pre-diabetes. Patients with pre-diabetes are eligible for a screening once every 6 months and once every 12 months for everyone else.
- CPT G0402/G0438/G0439 as part of Medicare's initial or annual wellness visit.
- Eligibility: ACA mandated no-cost coverage for adults 65 years old and over who live in a community setting. Fall prevention is often discussed during Medicare's annual wellness visit.
Hepatitis B screening
- CPT G0499 — Hepatitis b screening in non-pregnant, high risk individual includes hepatitis b surface antigen (hbsag) followed by a neutralizing confirmatory test for initially reactive results, and antibodies to hbsag (anti-hbs) and hepatitis b core antigen (anti-hbc)
- Other CPT codes may apply for pregnant women.
- Eligibility: ACA ensured that this screening is covered for people who are considered high risk and for people who are from countries with high rates of hepatitis B prevalence. Patients are also eligible for screening if they were born in the United States and not vaccinated as an infant with one parent from a region with a hepatitis B prevalence rate of at least 8%. Medicare covers hepatitis screenings for both pregnant and non-pregnant women as well as asymptomatic adolescents and adults at high risk for hepatitis B infection.
Hepatitis C screening
- CPT G0472 — Hepatitis c antibody screening, for individual at high risk and other covered indication(s)
- Eligibility: Patients who had a blood transfusion prior to 1992 and adults who were born between 1945 and 1965 are eligible for screening once per lifetime and annually for high-risk patients.
- CPT G0432 — Infectious agent antibody detection by enzyme immunoassay (eia) technique, hiv-1 and/or hiv-2 screening.
- CPT G0433 — Infectious agent antibody detection by enzyme-linked immunosorbent assay (elisa) technique, hiv-1 and/or hiv-2, screening.
- CPT G0435 — Infectious agent antibody detection by rapid antibody test, hiv-1 and/or hiv-2 screening.
- CPT G0475 — HIV antigen/antibody, combination assay, screening.
- Eligibility: This screening is for everyone ages 15 to 65 and can be performed annually. All other ages are eligible for patients who have increased risk factors. There are several CPT codes relevant to HIV screening.
- CPT 90670 — Pneumococcal conjugate vaccine, 13 valent (PCV13), for intramuscular use.
- CPT 90732 — Pneumococcal polysaccharide vaccine, 23-valent (PPSV23), adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use.
- CPT G0009 — Administration of pneumococcal vaccine
- A list of CPT codes and their specific descriptions for the influenza vaccine can be found here.
- Eligibility: ACA mandated provisions for all recommended vaccines for both adults and children. Patients with Medicare Part B are encouraged to receive a pneumococcal vaccine and an annual influenza vaccine. The pneumococcal vaccine eligibility is subject to Medicare criteria.
Intensive behavioral therapy for cardiovascular disease (CVD)
- CPT G0446 — Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes.
- Eligibility: All adults once per year.
Lung cancer CT counseling and screening
- CPT G0296 — Counseling visit to discuss need for lung cancer screening using low dose CT scan (LDCT)
- CPT G0297 — Low dose CT scan (LDCT) for lung cancer screening
- Eligibility: ACA mandated that high-risk adults who currently or previously smoked within the last 15 years and are between the ages 55 and 80 years old are eligible to receive a lung cancer screening. Medicare beneficiaries may receive a lung cancer screening if they are asymptomatic; have a tobacco use history of at least one pack per day over a 30-year period; are a current smoker; or quit within the last 15 years.
Medical nutrition therapy (MNT)
- CPT 97802 — Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes
- CPT 97803 — Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes
- Eligibility: For adults with diabetes, renal disease or who have had a kidney transplant
Obesity screening and counseling
- CPT G0447 — Face-to-face behavioral counseling for obesity, 15 minutes
- CPT G0473 — Face-to-face behavioral counseling for obesity, group (2-1), 30 min
- Eligibility: Payers must provide coverage for obesity screening and counseling for all members. Medicare beneficiaries who have a BMI greater than 30, are competent and alert, and see a qualified practitioner or primary care provider are eligible to receive up to 22 obesity counseling visits in a 12-month period. Visits taper over time. A list of Medicare coverage rules can be found here.
Sexually transmitted infection prevention counseling
- CPT — A list of sexually transmitted infection CPT codes can be found here.
- Eligibility: ACA expanded coverage for all adults at high risk of contracting a sexually transmitted disease.
- CPT 86592 — Syphilis test, non-treponemal antibody; qualitative (eg, VDRL, RPR, ART)
- CPT 86593 — Syphilis test, non-treponemal antibody, quantitative
- CPT 86780 — Antibody; treponemal pallidum
- Eligibility: All at-risk adults are eligible to receive screenings for syphilis.
Tobacco use screening
- CPT 99406 — Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes
- CPT 99407 — Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes
- Eligibility: All adult tobacco users are eligible for screening and cessation interventions regardless of tobacco-related disease symptoms. Per Medicare, patients must be alert and competent and consequent counseling must be performed by a qualified practitioner.
- CPT 86580 — Skin test, tuberculosis, intradermal
- Eligibility: This screening service is covered for adults meeting certain criteria and are without symptoms or are at a high risk of contracting tuberculosis.
Checking Every Prevention Box
For preventive services under the ACA to be effective, it's important to ensure patients eligible to receive preventive care are doing so. For most older adults, many of the aforementioned preventive services can be combined as part of the Medicare annual wellness visit. When these services are performed and billed properly, it can benefit your patients and bolster your practice's bottom line.
In response to increasing need and demand, healthcare IT companies, such as Prevounce, have risen to the challenge, creating easy-to-use and effective tools and support programs that help make the provision of preventive services easier and more lucrative for practitioners and their practice. Learn more about the Prevounce platform and what it can do for you by clicking here.
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