Preventive Medicine

CMS.gov Information on Essential Health Benefits (EHB) Benchmark Plans Used with the Affordable Care Act

Use the box on the right to get a list of A, and B recommendations from the USPTF (with the ability to print)

NEWS:

MLN Educational Tool: Medicare Preventive Services Chart (2024)

U.S. Preventive Service Task Force (USPSTF) Recommendations

Medicare Claims Processing Manual: Chapter 18 - Preventive and Screening Services (verify current revision) 


Preventive Medicine Coding and Billing Info

State Essential Health Benefit (EHB) Plans: The Affordable Care Act requires non-grandfathered health plans in the individual and small group markets to cover essential health benefits (EHB). HHS regulations (45 CFR 156.100, et seq.) define EHB based on State-specific EHB-benchmark plans. CMS lists the EHB benchmark plans for each of the 50 states and the District of Columbia (D.C.). 

Telehealth applicable codes will be indicated with a phone icon. 

Click on the topic you’re interested in below to view the information. Scroll down to review all topics. Click here to see published recommendations according to population/grade per U.S. Preventive Services Task Force Grade A-B Recommendations.
NOTE: This educational tool is not meant to be viewed as coding or billing guidelines.

Resources

Preventive Medicine Topics

Select the title to see a summary and a link to the full article.  some articles require a subscription to view.

Apr 20th, 2023

Problem Lists vs. Reality: Improving Risk Adjustment Coding Accuracy for Medicare Advantage Plans

by  Jessica Hocker, CPC, CPB, CRC

Accurate risk adjustment coding is crucial for Medicare Advantage plans to receive appropriate funding and provide quality care to their members. However, problem lists, which are often incomplete or inaccurate, can pose significant challenges. This article presents possible targeted strategies in addressing the "problem" of problem lists, such as utilization of claims data, clinical documentation improvement, and provider education.
Nov 23rd, 2022

2022-11-23-MLNC - Weekly Edition

Colorectal Cancer Screening Test: Reduced Coinsurance for Related Procedures Begins January 1 - - Ambulance Fee Schedule: CY 2023 Inflation Factor & Productivity Adjustment - - Medicare Ground Ambulance Data Collection System: Information to Help You Report - -...
Aug 21st, 2022

CMS Encourages Medicaid MCOs and CHIP to Employ Section Waivers to Improve SDoH and Reduce Healthcare Costs

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Over the past few years, at least 15 states have consistently pursued the goal of using social determinants of health (SDOH) in their overall healthcare analysis and treatment programs for patients, and CMS has taken notice. Data and outcomes obtained from these state programs have essentially provided an outline of how the government intends to pursue health equity through managed care contracts (MCOs) and Children's Health Insurance Program (CHIP). What is CMS seeing that they like so much and how might that affect future MCO contracts?
Jul 21st, 2022

Addressing Trauma and Mass Violence

by  Amanda Ballif

After events of mass violence, it’s easy to feel helpless, like there is little we can do. In fact, we can help individuals, families, and communities build resilience and connect with others to cope together. The SAMHSA-funded National Child Traumatic Stress Network has developed a range of resources to help children, families, educators, and communities including the following which you can access via links in this article.
Jul 14th, 2022

HHS Leaders Urge States to Maximize Efforts to Support Children’s Mental Health

by  SAMSHA Newsroom

Today, agencies across the U.S. Department of Health and Human Services (HHS) issued a joint letter to states, tribes, and jurisdictions encouraging them to prioritize and maximize their efforts to strengthen children’s mental health and well-being. The letter, signed by leaders of the Health Resources and Services Administration (HRSA), the Substance Abuse and Mental Health Services Administration (SAMHSA), the Centers for Medicare & Medicaid Services (CMS), the Centers for Disease Control and Prevention (CDC), the Administration for Children and Families (ACF), and the Administration for Community Living (ACL), outlines HHS’ plans to support and facilitate state-level coordination across federal funding streams to advance and expand mental health services for children.
Jun 16th, 2022

2022-05-26-MLNC - Biosimilars: Interchangeable Products May Increase Patient Access

by  CMS - MLNConnects

News - COVID-19: New Administration Code for Pfizer Pediatric Vaccine Booster Dose - - Biosimilars: Interchangeable Products May Increase Patient Access - - Critical Care Evaluation & Management Services: Comparative Billing Report in May - -...
May 26th, 2022

Preventive Medicine Versus E&M Codes: The Same-Day Coding Dilemma

by  Terry Fletcher, CPC CCC CEMC CCS CCS-P CMC CMSCS CMCS ACS-CA SCP-CA QMGC QMCRC

Choosing a proper office visit code can become confusing unless one understands the rules separating preventive medicine and evaluation and management (E&M) coding. Problem-oriented E&M services, office, and other outpatient visit codes 99202-99215 (along with hospital, observation, and consultative encounters) are for patients who present with signs, symptoms,...
May 17th, 2022

Understanding the Basics of Reporting Mammography Services

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

How familiar are you with the coding and documentation requirements for screening and diagnostic mammography? What is diagnostic digital breast tomosynthesis and can you bill for it? This article review the basics of reporting screening, diagnostic, and digital breast tomosynthesis.
May 10th, 2022

Recent AMA Study Finds Half of Black Women Have High Blood Pressure

by  Terry Fletcher, CPC CCC CEMC CCS CCS-P CMC CMSCS CMCS ACS-CA SCP-CA QMGC QMCRC

Hypertension among Black Americans is among the highest in the world. Currently, the American Medical Association (AMA) is working to achieve optimal health for all. To do that, they need to work at the community level to bring health equity to minority communities in the U.S. A recent...
Apr 26th, 2022

Preventive Services

by  Shannon O. DeConda, CPC CPC-I CEMC CEMA CPMA CRTT

In Today’s Take, let’s discuss the difference between preventive care. You might be thinking this is “101”. But it really isn’t. Oftentimes, when conducting chart audits, we not only we see issues with a lack of documentation criteria, especially with Medicare preventive services, but we also see confusion regarding...
Apr 21st, 2022

2022-03-03-MLNC - 2022 Payment, Quality, & Policy Changes

by  CMS - MLNConnects

News - Ambulance Prior Authorization Model Expands April 1 - Nutrition-related Health Conditions: Recommend Medicare Preventive Services - Claims, Pricers, & Codes - HCPCS Application Summaries & Coding Decisions: Drugs and Biologicals - Events - ICD-10 Coordination & Maintenance Committee Meeting — March...
Mar 10th, 2022

2022-03-10-MLNC - COVID-19 Monoclonal Antibodies: Revised Emergency Use Authorization for EVUSHELD

by  CMS - MLNConnects

News - COVID-19 Monoclonal Antibodies: Revised Emergency Use Authorization for EVUSHELD - Program for Evaluating Payment Patterns Electronic Reports for Short-term Acute Care Hospitals - Quality Payment Program: 2020 Performance Information on Care Compare - Skilled Nursing Facilities: Submit Technical Expert Panel Nominations by March 16 ...
Oct 13th, 2021

New Codes for Pediatric COVID Vaccinations

by  Jared Staheli, MPP

On October 6, 2021, the AMA released three new codes to track COVID-19 vaccinations in the pediatric population.
Jun 1st, 2021

Chronic Care Management Services

by  Wyn Staheli, Director of Content - innoviHealth

This article discusses some of the different Chronic Care Management (CCM) Services found in both the CPT and HCPCS code sets. CCM is not the same as Case Management Services in that case management has to do with “coordinating, managing access to, initiating, and/or supervising'' patient healthcare services whereas CCM services also require the patient to have a condition(s) which is expected to last at least a year or until their death.
Sep 30th, 2019

Vaccine Administration - When The Right Vaccine Code is Not Enough

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

Understanding how to apply immunization administration codes properly will support correct reimbursement for vaccinations. Reporting the right vaccine code alone is not enough to guarantee proper billing. The majority of the time, providers can charge for the vaccine/product as well as the administration of the vaccine; always consult your payer ...
Feb 12th, 2019

Coding Medicare Initial Preventive Physical Exams (IPPE)

by  Aubrie Rowley

The Medicare Initial Preventive Physical Exam (IPPE), also commonly referred to as the “Welcome to Medicare Physical”, may seem daunting to many, but when broken out to identify the requirements is fairly straightforward. Purpose An IPPE helps the Medicare beneficiary (the patient) get to know their healthcare provider at a time when they ...
Nov 1st, 2018

CMS: Medicare Diabetes Prevention Program Expanded Model

by  Find-A-Code™

CMS announces the Medicare Diabetes prevention program is now a new covered service. Per a recent MLN news release. Medicare Beneficiaries will be notified in 2019 in a Medicare handout. Diabetes affects more than 25 percent of Americans aged 65 or older, and its prevalence is projected to increase approximately...
May 9th, 2018

Preventive Medicine: Alcohol Misuse Screening & Counseling

by  Find-A-Code™

Preventive Medicine Topics Page // Alcohol Misuse Screening and Counseling Procedure Codes G0442: Annual alcohol misuse screening, 15 minutes G0443: Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes 99408: Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to ...
May 9th, 2018

Preventive Medicine: Annual Wellness Visit

by  Find-A-Code™

Preventive Medicine Topics Page Annual Wellness Visit Procedure Codes G0438: Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit G0439: Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit 99385: Initial comprehensive preventive medicine evaluation and management of an individual including ...
May 9th, 2018

Preventive Medicine: Breast Cancer Genetic Screening

by  Find-A-Code™

Preventive Medicine Topics Page Breast Cancer Genetic Screening Procedure Codes 81211: BRCA1, BRCA2 (breast cancer 1 and 2) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis and common duplication/deletion variants in BRCA1 (ie, exon 13 del 3.835kb, exon 13 dup 6kb, exon 14-20 del 26kb, exon 22 ...

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Jan 4th, 2018

Proper Coding and Billing for Drugs, Biologicals and Injections 

by  Find-A-Code™

Proper Coding and Billing for Drugs, Biologicals and Injections

Links and resources by topic.

Plan networks and government plans are required to cover preventive services as required by the Affordable Care Act (ACA) at no cost to the patient. This covers numerous screenings, counseling and well visits to prevent illness, disease and health problems. Services are based on age, gender, and other health factors. This does not include diagnostic testing as this is not considered preventive. Preventive services must be performed by a covered provider, in-network and may be used to develop a wellness plan to keep the patient healthy.

This page was created from a need to have all of the information in one place to accommodate Payers, Providers, Researchers, and others, suggestions and feedback are always welcome, please send it to us at Support@Findacode.com. The information covered on this page is informational only and not meant to be all-inclusive, always verify coverage with your payer.

For more information about the Affordable Care Act visit HHS.gov


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