1.0 CPT
PROCEDURE CODES
45300 - 45305, 45308 - 45315,
45320, 45321, 45330, 45331, 45333, 45338, 45346, 45378, 45380, 45384,
45385, 45388, 74263, 76977, 77058, 77059, 77065
- 77067, 77078 - 77081, 80061, 81528, 82270, 82274,
82465, 82947 - 82952, 83036, 83718 - 83721, 84152 - 84154, 84478,
86480, 86481, 86580, 86592, 86593, 86631, 86632, 86689, 86701 -
86706, 86762, 86780, 86803, 86804, 87110, 87270, 87320, 87340, 87341,
87389 - 87391, 87490 - 87492, 87534 - 87536, 87590 - 87592, 87623
- 87625, 87800, 87801, 87806, 87810, 87850, 88141 - 88155, 88160
- 88162, 88164 - 88167, 88174, 88175, 92002, 92004, 92012, 92014,
92015, 97802 - 97804, 99172, 99173, 99383 - 99387, 99393 - 99397,
99401 - 99404
2.0 HCPCS
PROCEDURE CODES
Level II Codes G0101 - G0105,
G0121, G0123, G0124, G0130, G0141 - G0148, G0270,
G0271, G0328, G0445, G0472, G0473, G0475, G0499,
S9470
3.0 POLICY
Preventive
care is not directly related to specific illness, injury, a definitive
set of symptoms, or obstetrical care, but rather is performed as
a periodic health screening, health assessment, or periodic health
maintenance.
The National Defense
Authorization Act (NDAA) for Fiscal Year (FY) 2009 (Public Law 110-417, Section
711) waived cost-share requirements for certain preventive services
rendered on or after October 14, 2008. (See the TRICARE Reimbursement
Manual (TRM),
Chapter 2, Section 1 for services for which
cost-shares were eliminated.)
Effective
January 1, 2017, cost-shares are also eliminated for the services
listed in
paragraphs 3.1.1.1.2 and
3.1.5.1 through
3.1.5.12.
Effective January 1, 2018, cost-shares are
eliminated for the services listed in
paragraph 3.1.5.13.
See
Section 2.2,
for the clinical preventive services covered under TRICARE Prime
and TRICARE Select.
Covered services
as identified in this policy are based on recommendations from the
United States Department of Health and Human Services (HHS). This
includes recommendations from the United States Preventive Services
Task Force, the Health Resources and Services Administration, etc.
The services identified in this policy are
applicable to beneficiaries age six years and older. For beneficiaries
under age six, covered preventive services are identified in the
TRICARE well-child care policy. (See
Section 2.5.)
A 30 day administrative tolerance will be allowed
for any time interval requirements imposed on services covered by
this policy; e.g., if an asymptomatic woman 40 years of age or older
received a screening mammography on September 15, coverage for another
screening mammography would be allowed on or after August 17 of
the following year.
3.1
Covered
Services Exempt from Cost-Share Requirements
The
following preventive services are covered and exempt from cost-share
requirements:
3.1.1
Cancer
Screening Examinations and Services
3.1.1.1 Breast
Cancer
3.1.1.1.1 Clinical Breast Examination
(CBE)
A CBE may be performed during a covered
Health Promotion and Disease Prevention examination.
3.1.1.1.2
BRCA1
Or BRCA2 Genetic Counseling And Testing
3.1.1.1.2.1 Genetic
counseling rendered by a TRICARE-authorized provider that precedes
BRCA1 or BRCA2 gene testing is covered for women who are identified
as high risk for breast cancer by their primary care clinician.
3.1.1.1.2.2 BRCA1 or BRCA2 gene testing is covered for
women who meet the coverage guidelines outlined in the TRICARE Operations
Manual (TOM),
Chapter 18, Section 3, Figure 18.3-1.
3.1.1.1.3
Screening
Mammography
3.1.1.1.3.1 Screening
mammography is covered annually for all women beginning at age 40.
3.1.1.1.3.2 Screening
mammography is covered annually beginning at age 30 for women who have
a 15% or greater lifetime risk of breast cancer (according to risk
assessment tools based on family history such as the Gail model,
the Claus model, and the Tyrer-Cuzick model), or who have any of
the following risk factors:
3.1.1.1.3.2.1 History
of breast cancer, Ductal Carcinoma In Situ (DCIS), Lobular Carcinoma
In Situ (LCIS), Atypical Ductal Hyperplasia (ADH), or Atypical Lobular
Hyperplasia (ALH);
3.1.1.1.3.2.2 Extremely dense breasts when viewed by mammogram;
3.1.1.1.3.2.3 Known BRCA1
or BRCA2 gene mutation;
3.1.1.1.3.2.4 First-degree relative (parent, child, sibling)
with a BRCA1 or BRCA2 gene mutation, and have not had genetic testing
themselves;
3.1.1.1.3.2.5 Radiation
therapy to the chest between the ages of 10 and 30 years; or
3.1.1.1.3.2.6 History
of Li-Fraumeni, Cowden, or Bannayan-Riley-Ruvalcaba syndrome, or
a first-degree relative with a history of one of these syndromes.
Note: The risk factors identified above for a screening
mammography are those established by the American Cancer Society.
3.1.1.1.4 Breast Magnetic Resonance
Imaging (MRI)
3.1.1.1.4.1 Breast
MRI is covered annually, in addition to the annual screening mammogram, beginning
at age 30 and at age 35 for services rendered prior to September
7, 2010, for women who have a 20% or greater lifetime risk of breast
cancer (according to risk assessment tools based on family history
such as the Gail model, the Claus model, and the Tyrer-Cuzick model),
or who have any of the following risk factors:
3.1.1.1.4.1.1 Known BRCA1 or BRCA2 gene mutation;
3.1.1.1.4.1.2 First-degree
relative (parent, child, sibling) with a BRCA1 or BRCA2 gene mutation, and
have not had genetic testing themselves;
3.1.1.1.4.1.3 Radiation therapy to the chest between the
ages of 10 and 30; or
3.1.1.1.4.1.4 History of LiFraumeni, Cowden, or Bannayan-Riley-Ruvalcaba
syndrome, or first-degree relative with a history of one of these
syndromes.
Note: The risk factors identified above for a breast
cancer screening MRI are those established by the American Cancer
Society.
3.1.1.2 Cervical
Cancer
3.1.1.2.1 Pelvic Examination
A pelvic examination should be performed as
part of a well woman exam and in conjunction with Papanicolaou (Pap)
smear testing for cervical neoplasms and premalignant lesions.
3.1.1.2.2 Pap Smears
3.1.1.2.2.1 For dates of service prior to May 8, 2015,
cancer screening Pap smears should be performed for women who are
at risk for sexually transmissible diseases, women who have or have
had multiple sexual partners (or if their partner has or has had
multiple sexual partners), women who smoke cigarettes, and women
18 years of age and older when provided under the terms and conditions
contained in the guidelines adopted by the Director, Defense Health
Agency (DHA). The frequency of the Pap smears will be at the discretion
of the patient and clinician but not less frequent than every three
years.
3.1.1.2.2.2 For dates
of service on or after May 8, 2015, cancer screening Pap smears
are covered for female beneficiaries beginning at age 21. Women
under age 21 should not be screened regardless of the age of sexual
initiation or other risk factors. The frequency of screening Pap
smears may be at the discretion of the patient and clinician; however,
screening Pap smears should not be performed less frequently than
once every three years.
3.1.1.2.3 Human
Papillomavirus (HPV) Deoxyribonucleic Acid (DNA) Testing
3.1.1.2.3.1 HPV DNA testing is covered as a cervical cancer
screening only when performed in conjunction with a Pap smear, and
only for women aged 30 and older.
3.1.1.2.3.2 To be eligible for reimbursement as a cervical
cancer screening, HPV DNA testing must be billed in conjunction
with a Pap smear that is provided to a woman aged 30 or older.
3.1.1.3 Colorectal
Cancer
3.1.1.3.1 The following
cancer screenings and frequencies are covered for individuals at
average risk for
colon cancer:
• Fecal Occult Blood
Testing (FOBT). Either guaiac-based or immunochemical-based testing
of three consecutive stool samples once every 12 months for beneficiaries who
have attained age 50 (i.e., at least 11 months have passed following
the month in which the last covered screening FOBT was done).
• Fecal
Immunochemical Testing (FIT-DNA). FDA approved stool DNA tests (e.g., Cologuard™)
once every three years beginning at age 50.
• Proctosigmoidoscopy
or Flexible Sigmoidoscopy. Once every three to five years beginning
at age 50.
• Computed Tomographic
Colonography (CTC). Once every five years beginning at age 50.
• Optical (Conventional)
Colonoscopy. Once every 10 years beginning at age 50.
3.1.1.3.2 A family
history of colorectal cancer or adenomatous polyps increases an
individual’s risk of colon cancer. The following identifies these
risk factors and the cancer screenings and frequencies covered for
individuals at
increased risk for colon cancer:
• One
or more first-degree relatives diagnosed with sporadic colorectal
cancer or an adenomatous polyp before the age of 60 or in two or
more first-degree relatives at any age. Optical colonoscopy should
be performed every three to five years beginning at age 40 or 10
years earlier than the youngest affected relative, whichever is
earlier.
• One
or more first-degree relatives diagnosed with sporadic colorectal
cancer or an adenomatous polyp at age 60 or older, or two second-degree
relatives diagnosed with colon cancer. Either flexible sigmoidoscopy
(once every five years) or optical colonoscopy (once every 10 years)
should be performed beginning at age 40.
3.1.1.3.3 Certain
other risk factors put an individual at
high risk for
colon cancer. The following identifies these risk factors and the
cancer screenings and frequencies covered for individuals at
high risk for
colon cancer:
• Individuals with known
or suspected Familial Adenomatous Polyposis (FAP). Annual flexible
sigmoidoscopy beginning at age 10 to 12.
• Family history of
Hereditary Non-Polyposis Colorectal Cancer (HNPCC) syndrome. Optical
colonoscopy should be performed once every one to two years beginning at
age 20 to 25, or 10 years younger than the earliest age of diagnosis
of colorectal cancer, whichever is earlier.
• Individuals diagnosed
with Inflammatory Bowel Disease (IBD), Chronic Ulcerative Colitis
(CUC), or Crohn’s disease. For these individuals, cancer risk begins
to be significant eight years after the onset of pancolitis or 10
to 12 years after the onset of left-sided colitis. For individuals
meeting these risk parameters, optical colonoscopy should be performed
every one to two years with biopsies for dysplasia.
Note: The risk factors
identified above for colorectal cancer are those established by
the American Cancer Society.
3.1.1.4 Prostate
Cancer
3.1.1.4.1 Rectal Examination
Digital rectal examination will be offered
annually for all men beginning at age 50 who have at least a 10
year life expectancy. It should also be offered to begin for men
age 45 and over with a family history of prostate cancer in at least
one other first-degree relative (father, brother, or son) diagnosed
with prostate cancer at an early age (younger than age 65) and to
all African American men aged 45 and over regardless of family history.
Testing should be offered to start at age 40 for men with a family
history of prostate cancer in two or more other family members.
3.1.1.4.2 Prostate-Specific Antigen
(PSA)
3.1.1.4.2.1 Annual
testing may be offered for the following categories of males:
• Men
aged 50 years and older.
• Men aged 45 years
and over with a family history of prostate cancer in at least one other
family member.
• African
American men aged 45 and over regardless of family history.
• Men aged 40 and over
with a family history of prostate cancer in two or more other family
members.
3.1.1.4.2.2 A discussion
between the beneficiary and his provider on the risks/benefits of
PSA testing is encouraged.
3.1.1.4.2.3 Screening may continue to be offered as long
as the individual has a 10 year life expectancy.
3.1.1.5 Other
The cancer screenings indicated below may be
performed during any covered office visit, and reimbursement is
included in the allowance for the visit.
3.1.1.5.1 Testicular
Cancer Screening
Examination of the testis
should be performed annually for males age 13-39 with a history
of cryptorchidism, orchiopexy, or testicular atrophy.
3.1.1.5.2 Skin
Cancer Screening
Examination of the skin
should be performed for individuals with a family or personal history
of skin cancer, increased occupational or recreational exposure
to sunlight, or clinical evidence of precursor lesions.
3.1.1.5.3 Oral
Cavity and Pharyngeal Cancer Screening
A
complete oral cavity examination should be part of routine preventive
care for adults at high risk due to exposure
to tobacco or excessive amounts of alcohol. Oral examination should
also be part of a recommended annual dental check-up.
3.1.1.5.4 Thyroid
Cancer Screening
Palpation for thyroid nodules
should be performed in adults with a history of upper body irradiation.
3.1.2
Immunizations
3.1.2.1 Coverage is extended for the age appropriate
dose of vaccines that meet the following requirements:
• The
vaccine has been recommended and adopted by the Advisory Committee
on Immunization Practices (ACIP) for use in the United States (U.S.);
and
• The
ACIP adopted recommendations have been accepted by the Director
of the Centers for Disease Control and Prevention (CDC) and the
Secretary of Health and Human Services (HHS) and published in a
CDC Morbidity and Mortality Weekly Report (MMWR).
• The
effective date of coverage for CDC recommended vaccines is the date
ACIP recommendations for the vaccine are published in a MMWR.
3.1.2.2 Refer to the CDC’s web site (
http://www.cdc.gov)
for a current schedule of CDC recommended vaccines for use in the
U.S.
3.1.2.3 Immunizations
recommended specifically for travel outside the U.S. are NOT covered, EXCEPT
for immunizations required by dependents of active duty military
personnel who are traveling outside the U.S. as a result of an active
duty member’s duty assignment, and such travel is being performed
under orders issued by a Uniformed Service. Claims must include
a copy of the travel orders or other official documentation verifying
the official travel requirement.
3.1.3
Health
Promotion And Disease Prevention (HP&DP) Examinations
HP&DP exams are covered when rendered in
connection with one of the cancer screenings listed in
paragraph 3.1.1 or
a covered immunization as delineated in
paragraph 3.1.2, or for well
woman exams as indicated in
paragraph 3.1.4.
3.1.4
Well
Woman Examinations
HP&DP exams for the
purpose of a well woman exam are covered annually for female beneficiaries
under age 65. If the primary care clinician determines that a patient
requires additional well woman visits to obtain all necessary recommended
preventive services that are age and developmentally appropriate,
these may be provided without cost-sharing and subject to reasonable medical
management. There is no requirement that a well woman exam (HP&DP
exam) be rendered in connection with a covered cancer screening
or immunization.
3.1.5
Other
Screenings And Services
The following services
are covered when rendered during a covered HP&DP exam or a well woman
exam, as delineated in
paragraphs 3.1.3 and
3.1.4, or when ordered/recommended
during one of these exams:
3.1.5.1 Tuberculosis
(TB) Screening. Screen annually, regardless of age, for all individuals
at high risk for TB (as defined by the CDC) using Mantoux
tests.
3.1.5.2 Rubella
Antibodies. Test females once, between ages 12-18, unless a history
of adequate rubella vaccination with at least one dose of rubella
vaccine on or after the first birthday is documented.
3.1.5.3 Hepatitis B Virus (HBV) Screening. Screen for
HBV in individuals at high risk for infection.
3.1.5.4 Hepatitis C Virus (HCV) Screening. Screen for
HCV in individuals at high risk for infection and as
a one-time screening for adults born between 1945 and 1965.
3.1.5.5 Diabetes Mellitus (Type II) Screening. Screen
adults with a sustained blood pressure (treated or untreated) greater
than 135/80 mmHg. Screen adults aged 40-70 who are overweight or obese.
3.1.5.6 Human Immunodeficiency Virus (HIV) Infection
Screening. Screen for HIV in individuals ages 15-65. Younger adolescents
and older adults who are at increased risk should also
be screened.
3.1.5.7 Syphilis
Infection Screening. Screen at risk individuals for syphilis infection.
3.1.5.8 Chlamydia and Gonorrhea Screening. Screen sexually
active women age 24 years and younger and older women who are at increased
risk for infection.
3.1.5.9 Cholesterol
Screening. Screen children once between the ages of 9 and 11 and
again between the ages of 17 and 21. Screen men age 35 and older.
Screen men and women age 20 and older who are at increased
risk for coronary heart disease.
3.1.5.10 Blood Pressure Screening. Blood pressure screening
at least every two years after age six.
3.1.5.11 Osteoporosis Screening. Screen women for osteoporosis
whose fracture risk is equal to or greater than that of a 65 year
old white woman who has no additional risk factors.
3.1.5.12 Intensive
Behavioral Counseling for Sexually Transmitted Infections (STIs).
Intensive behavioral counseling (counseling that lasts more than
30 minutes) for all sexually active individuals who are at increased
risk for STIs is covered when rendered by a TRICARE authorized
provider.
3.1.5.13 Intensive,
Multicomponent Behavioral Interventions for Obesity. For adults
with a Body Mass Index (BMI) of 30 kg/m2 or higher and for children/adolescents
with a BMI value greater than the 95th percentile, intensive, multicomponent
behavioral interventions to promote sustained weight loss (12 to
26 sessions in a year) are covered when rendered by a TRICARE authorized
provider. Intensive, multicomponent behavioral interventions include,
but are not limited to: behavioral management activities such as
setting weight-loss goals; diet and physical activity guidance;
addressing barriers to change; active self-monitoring; and, strategies
to maintain lifestyle changes.
3.1.6 Breast
Pumps, Breast Pump Supplies, and Breastfeeding Counseling
For coverage of breast pumps, breast pump supplies
and breastfeeding counseling, see
Chapter 8, Section 2.6.
3.1.7 Well-Child
Care
For coverage of well-child care, see
Section 2.5.
3.2 Covered
Services Not Exempt From Cost-Sharing Requirements
Regular cost-sharing requirements apply to
the following services:
3.2.1 School Physicals
Physical examinations required in connections
with school enrollment are covered.
3.2.2 Physical
Examinations Required For Travel Outside the United States - Orders Required
A physical examination provided when required
in the case of a family member who is traveling outside the United
States as a result of the member’s assignment and such travel is
being performed under orders issued by a Uniformed Service is covered.
Claims must include a copy of the travel orders or other official
documentation verifying the official travel requirement.
3.2.3 Routine
Eye Examinations
One routine eye exam per
calendar year per person is covered for family members of Service members. Routine
eye exams are excluded for retirees and their family members. See
Section 6.1.
Note: Routine eye exams
are meant to be more than the standard visual acuity screening test conducted
by the member’s primary care physician through the use of a standard
Snellen wall chart.
Note: TRICARE diabetic beneficiaries may receive medically
necessary eye exams IN ADDITION to the routine eye exams they receive
as a preventive benefit.
3.2.4 Audiology
Screening
Preventive hearing examinations
are only allowed under the well-child care benefit.
3.3 Other
The following services are covered as expected
components of good clinical practice and are integrated into the
appropriate office visit at no additional charge:
3.3.1 Counseling
3.3.1.1 Patient
and parent education and counseling for:
• Accident and injury
prevention;
• Cancer
surveillance;
• Depression, stress,
bereavement, and suicide risk assessment;
• Dietary assessment
and nutrition;
• Intimate partner
violence and abuse;
• Physical activity
and exercise;
• Promoting dental
health;
• Risk
reduction for skin cancer;
• Safe
sexual practices; and
• Tobacco,
alcohol and substance abuse.
3.3.2 Body
Measurements
For adults, height and weight
is typically measured and BMI calculated at each primary care visit.
Individuals identified with a BMI of 25 or above typically receive
appropriate nutritional and physical activity counseling as part
of the primary care visit. For children and adolescents, height
and weight typically is measured and BMI-for-age calculated and
plotted at each primary care visit using the CDC “Data Table of
BMI-for-age Charts”. Children/adolescents with a BMI value greater
than the 85th percentile typically receive appropriate nutritional
and physical activity counseling as part of the primary care visit.
4.0 EFFECTIVE DATES
4.1 The NDAA for FY 2009 (Public Law 110-417, Section
711) waived cost-share requirements for certain preventive services
rendered on or after October 14, 2008. (See the TRM,
Chapter 2, Section 1 for services for which
cost-shares were eliminated.)
4.3 Effective January 1, 2018,
cost-shares are eliminated for the services listed in
paragraph 3.1.5.13.
4.4 For the benefits under this program, the effective
date of coverage is the publication date of the corresponding recommendation
from the HHS.