|
HEALTH PROMOTION
AND DISEASE PREVENTION (HP&DP) EXAMINATIONS
|
For ages six
year and or older: One HP&DP examination is covered annually.
|
CPT codes 99383
- 99387 and 99393 - 99397.
|
|
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 copay and subject to
reasonable medical management.
|
CPT codes 99383
- 99386 and 99393 - 99396.
|
|
TARGETED
CLINICAL PREVENTIVE SERVICES
|
The
following clinical preventive services may be performed during either
an HP&DP exam or a well woman exam.
|
|
Breast
Cancer:
|
Clinical
Breast Examination (CBE): A CBE may be performed during a
covered HP&DP exam.
|
See appropriate
level evaluation and management codes and HCPCS code G0101.
|
|
BRCA1
or BRCA2 Genetic Counseling and Testing: 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.
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. |
CPT codes 99401
- 99404.
|
|
|
Screening
Mammography: Covered annually for all women beginning at
age 40. 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:
1. History of breast cancer, Ductal Carcinoma
In Situ (DCIS), Lobular Carcinoma In Situ (LCIS), Atypical Ductal
Hyperplasia (ADH), or Atypical Lobular Hyperplasia (ALH);
2. Extremely dense breasts when viewed by
mammogram;
3. *Known
BRCA1 or BRCA2 gene mutation;
4.
*First-degree relative (parent, child, sibling) with a BRCA1 or BRCA2
gene mutation, and have not had genetic testing themselves;
5. Radiation therapy to the chest between
the ages of 10 and 30 years; or
6. History of Li-Fraumeni, Cowden, or Bannayan-Riley-Ruvalcaba
syndrome, or a first-degree relative with a history of one of these
syndromes.
|
CPT codes 77067.
|
|
|
Note: The
risk factors identified above for screening mammography are those
established by the American Cancer Society.
|
|
|
Breast
Screening Magnetic Resonance Imaging (MRI): Covered annually,
in addition to the annual screening mammogram, beginning at age
30 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:
1. *Known BRCA1 or BRCA2 gene mutation;
2. First-degree relative (parent, child,
sibling) with a BRCA1 or BRCA2 gene mutation, and have not had genetic
testing themselves;
3.
Radiation to the chest between the ages of 10 and 30; or
4. History of LiFraumeni, Cowden, or Bannayan-Riley-Ruvalcaba syndrome,
or a first-degree relative with a history of one of these syndromes.
|
CPT codes 77058
and 77059.
|
|
|
Note:
The risk factors identified above for breast cancer screening MRI
are those established by the American Cancer Society.
|
|
Cervical
Cancer
|
Pelvic
Examination: A pelvic examination should be performed as
part of a well woman exam and in conjunction with Pap smear testing
for cervical neoplasms and premalignant lesions.
|
See appropriate
level evaluation and management codes and HCPCS code G0101.
|
|
|
Pap Smears:
For dates of service prior to May 8, 2015, cancer screening Pap
smears should be performed for women who are at risk for sexually
transmittable 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 screening Pap smears will be at the discretion of the patient
and clinician but not less frequent then every three years.
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.
|
CPT codes 88141
- 88155, 88160 - 88162, 88164 - 88167, 88174, and 88175.
HCPCS codes G0123, G0124, and G0141 - G0148.
|
|
|
Human
Papillomavirus (HPV) Deoxyribonucleic Acid (DNA) Testing:
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.
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.
|
CPT codes 87623
- 87625.
|
|
Colorectal
Cancer:
|
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
must have passed following the month in which the last covered screening
fecal-occult blood test was done).
|
CPT codes 82270
and 82274.
HCPCS code
G0328.
|
|
Fecal
Immunochemical Testing (FIT-DNA): FDA approved stool DNA
tests (e.g., Cologuard™) once every three years beginning at age
50.
|
CPT code 81528
|
|
|
Proctosigmoidoscopy
or Flexible Sigmoidoscopy: Once every three to five years
beginning at age 50.
|
CPT codes 45300
- 45305, 45308 - 45315, 45320, 45321, 45330, 45331, 45333, 45338,
and 45346.
HCPCS code
G0104.
|
|
Computed
Tomographic Colongraphy (CTC): Once every five years beginning
at age 50.
|
CPT code 74263.
|
|
|
Optical
(Conventional) Colonoscopy: Once every 10 years beginning
at age 50.
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.
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.
|
CPT codes 45378,
45380, 45384, 45385, and 45388.
HCPCS codes G0105 and G0121.
|
|
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.
|
|
|
Prostate
Cancer:
|
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.
|
See appropriate
level evaluation and management codes and HCPCS code G0102.
|
|
Prostate-Specific
Antigen (PSA): Annual testing for the following categories
of males may be offered:
1.
Men aged 50 years and older.
2. Men aged 45 years and over with a family
history of prostate cancer in at least one other family member.
3. African American men aged 45 and over
regardless of family history.
4.
Men aged 40 and over with a family history of prostate cancer in
two or more other family members.
A discussion between the beneficiary and
his provider on the risks/benefits of PSA testing is encouraged.
|
CPT codes 84152
- 84154.
HCPCS code G0103.
|
|
Testicular
Cancer:
|
Physical
Examination: Examination of the testis should be performed
annually for males age 13-39 with a history of cryptorchidism, orchiopexy,
or testicular atrophy.
|
See appropriate
level evaluation and management codes.
|
|
Skin
Cancer:
|
Physical
Examination: 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.
|
See appropriate
level evaluation and management codes.
|
|
Oral
Cavity and Pharyngeal Cancer:
|
Physical
Examination: 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.
|
See appropriate
level evaluation and management codes.
|
|
Thyroid
Cancer:
|
Physical
Examination: Palpation for thyroid nodules should be performed
in adults with a history of upper body irradiation.
|
See appropriate
level evaluation and management codes.
|
|
Lung
Cancer:
|
Low-Dose
Computed Tomography: Screening covered annually for persons
55 through 80 years of age with a 30 pack per year history of smoking
who are currently smoking or have quit within the past 15 years.
Screening should be discontinued once the individual has not smoked
for 15 years or develops a health problem significantly limiting
either life expectancy or ability or willingness to undergo curative
lung surgery.
|
CPT code 71250
HCPCS code G0297.
|
|
Immunizations:
|
Coverage is
extended for the age appropriate dose of vaccines that meet the
following requirements:
1.
The vaccine has been recommended and adopted by the Advisory Committee
on Immunization Practices (ACIP) for use in the United States; and
2. 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).
3. The effective date of coverage for CDC
recommended vaccines is the date ACIP recommendations for the vaccine
are published in an MMWR.
Refer
to the CDC’s web site ( http://www.cdc.gov)
for a current schedule of CDC recommended vaccines for use in the
United States. Immunizations
recommended specifically for travel outside the United States are
NOT covered, EXCEPT for immunizations required by dependents of
active duty military personnel who are traveling outside the United
States 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.
|
|
|
Infectious Diseases:
|
Tuberculosis
(TB) Screening: Screen annually, regardless of age, all individuals
at high risk for tuberculosis (as defined by the CDC
using Mantoux tests).
|
CPT codes 86480,
86481, and 86580.
|
|
|
Rubella
Antibodies: Test females, once, between the ages of 12 and
18, unless documented history of adequate rubella vaccination with
at least one dose of rubella vaccine on or after the first birthday
is documented.
|
CPT code 86762.
|
|
|
Hepatitis
B Virus (HBV) Screening: Screen for HBV in individuals at high
risk for infection.
|
CPT codes 86704
- 86706, 87340, and 87341.
HCPCS
code G0499.
|
|
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.
|
CPT codes 86803
and 86804.
HCPCS code
G0472.
|
|
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.
|
CPT codes 86689,
86701 - 86703, 87389 - 87391, 87534 - 87536, and 87806.
HCPCS code G0475.
|
|
Syphilis
Infection Screening: Screen at risk individuals for syphilis
infection.
|
CPT codes 86592,
86593, and 86780.
|
|
Chlamydia
and Gonorrhea Screening: Screen sexually active women age
24 years and younger and older women who are at increased
risk for infection.
|
CPT codes 86631,
86632, 87110, 87270, 87320, 87490 - 87492, 87590 - 87592, 87800,
87801, 87810, and 87850.
|
|
Diabetes
Mellitus (Type II):
|
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.
|
CPT codes 82947
- 82952 and 83036.
|
|
Cardiovascular Diseases:
|
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.
|
CPT codes 80061,
82465, 83718 - 83721, and 84478.
|
|
|
Blood
Pressure Screening: At least every two years after age six.
|
See appropriate
level evaluation and management codes.
|
|
|
Abdominal
Aortic Aneurysm (AAA): One time AAA screening by ultrasonography
for men, age 65 - 75, who have ever smoked.
|
CPT code 76700,
76706, and 76775.
|
|
Osteoporosis:
|
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.
|
CPT codes 76977
and 77078 - 77081.
HCPCS
code G0130.
|
|
Intensive Behavioral Counseling
for Sexually Transmitted Infections (STIs):
|
Intensive
Behavioral Counseling for 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.
|
CPT codes 99401
- 99404.
HCPCS code G0445.
|
|
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.
|
CPT codes 97802
-97804, 99401, and 99402.
HCPCS
codes G0270, G0271, G0447, G0473, and S9470.
|
|
Prenatal Screening
Tests:
|
|
|
|
Breast
Pumps, Breast Pump Supplies, and Breastfeeding Counseling:
|
|
|
|
Well-Child
Care:
|
|
|
|
Other:
|
School
Physicals: Physical examinations required in connection with
school enrollment are covered.
|
CPT codes 99383
and 99393.
|
|
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.
|
See appropriate
level evaluation and management codes.
|
|
|
Body Measurement: 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. Head circumference typically is measured through
age 24 months.
For
adults: Height and weight typically is 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 primary care visit.
|
See appropriate
level evaluation and management codes.
|
|
|
Vision
Care: Routine eye exam once every two years for retirees
and eligible family members who are enrolled in Prime. Routine eye
exams are not a covered benefit for retirees and eligible family
members who are enrolled in TRICARE Select. Active Duty Family Members
(ADFMs) who are enrolled in Prime or Select may receive a routine
eye exam annually (see Section 6.1).
|
CPT codes 92002,
92004, 92012, 92014, 92015, 99172, and 99173.
|
|
|
Note: Routine eye examinations 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. Self-referral will be allowed
for routine eye examinations since PCMs are incapable of providing
this service (i.e., a Prime beneficiary will be allowed to set up
his or her own appointment for a routine eye examination with any
network optometrist or ophthalmologist).
|
|
Note: TRICARE diabetic beneficiaries
may receive medically necessary eye exams IN ADDITION to the routine
eye exams they receive as a preventive benefit.
|
|
Note: When a beneficiary’s eligibility
status changes from Active Duty Service Member (ADSM) or Prime ADFM to
Prime retiree or retiree family member, the two-year time requirement
between routine eye examinations will start on the date of the eligibility
status change. That is, a Prime retiree or retiree family member
will be eligible for a routine eye examination in the first year
of the status change regardless of whether or not an examination
was performed in the previous year under ADFM eligibility status.
The eligibility status of the beneficiary will dictate the coverage parameters
of the eye examination.
|
|
|
Hearing
Screening: A hearing evaluation should be a part of routine
examinations for all children, and those with possible hearing impairment
should be referred for appropriate testing.
|
See appropriate
level evaluation and management codes.
|
|
|
Patient
& Parent Education And Counseling:
• Accident & Injury
Prevention;
• Cancer surveillance;
• Depression, stress,
bereavement, & suicide risk assessment;
• Dietary assessment
& nutrition;
• Intimate partner
violence and abuse;
• Physical activity
& exercise;
• Promoting dental
health;
• Risk reduction for skin cancer;
• Safe sexual practices;
and
• Tobacco, alcohol and substance abuse.
|
These are expected
components of good clinical practice that are integrated into the
appropriate office visit at no additional charge.
|