Provider Notice issued 08/22/07

Coverage of Preventive Services for Adults

The Department of Healthcare and Family Services [HFS] is changing its policies for coverage of preventive services for adults. Effective July 1, 2007, the department began covering preventive evaluation and management office visits for adult participants, age 21 and older.

To receive reimbursement for these services, providers must bill one of the preventive evaluation and management CPT codes. CPT code range 99385-99387 will be reimbursed at a rate of $66.40 per visit, and CPT code range 99395-99397 will be reimbursed at $42.50 per visit. FQHCs, ERCs and RHCs will receive the medical encounter reimbursement rate for these services. The preventive evaluation and management CPT codes are limited to one preventive office visit per patient, per provider, per year.

The department is also clarifying its policy with regard to adult immunizations and screenings, which are a critical component of preventive and primary care. Immunizations and age-appropriate adult screening and diagnostic tests and procedures are covered services for adults for the prevention or diagnosis of a primary disease, or the prevention of complications of a chronic disease. Common examples of such services are influenza vaccine, pneumococcal vaccine, tetanus and diphtheria toxoids vaccine (Td), tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), mammograms, cholesterol screenings, and colorectal screenings. The department covers adult immunizations administered in accordance with the Center for Disease Control’s (CDC) recommended guidelines. Providers should bill using the appropriate CPT code for the individual service.

Questions regarding this notice may be directed to the Bureau of Comprehensive Health Services at 1-877-782-5565.

Theresa A. Eagleson, Administrator

Division of Medical Programs