Wellness Benefits Allow for USPSTF Approved Tests and Screenings
Blue Cross and Blue Shield of North Carolina (Blue Cross NC) encourages our members who are healthy to see their primary care physicians on an annual basis to receive preventive, physical exams - also known as wellness visits. Members with chronic conditions, as well as young children, pregnant women, and the elderly, should obtain care from their primary care physicians more frequently, and as needed, in addition to having their annual wellness visits.
During a wellness visit, it is appropriate for our members to receive US Preventive Services Task Force (USPSTF)-approved preventive tests and screenings to uncover possible illnesses before they develop into symptoms or problems. The goals of these tests are to:
- Provide the most accurate and up-to-date information about a specific member’s health
- Uncover conditions to improve the member’s health
- Prevent illness
The USPSTF publishes recommendations on the appropriate tests and screenings that have proven preventive value, as well as other tests and screenings, which are not included as recommended and why. Our members’ benefits allow for coverage consideration for tests and screenings recommended by USPSTF when those tests and screenings are provided as part of a wellness visit. However, other non-recommended tests and screenings are not eligible under our members’ annual wellness benefits.
Therefore, beginning January 1, 2018, tests and screenings not included as part of those recommended by USPSTF and ineligible under our members’ wellness benefits, will no longer be reimbursed when provided as part of a wellness visit and/or when submitted on a claim with a wellness diagnosis code of Z00.00, Z00.129, Z00.70 and or Z01.41.
The following are the most commonly-provided tests and screenings, which are for diagnostic purposes and not included, as recommended by USPSTF, for preventive testing. These diagnostic tests and screenings, if provided on or after January 1, 2018, will be denied as ineligible for reimbursement when provided as part of a wellness visit and/or submitted on a claim with a wellness diagnosis code:
- Urinalysis testing (CPT codes 81000, 81001, 81002, 81003, 81005, 81015)
- Thyroid function testing (CPT codes 84436, 84439, 84443, 84479, 84480, 84481)
- Vitamin D serum testing (CPT codes 83306, 82652)
- EKGs (CPT codes 93000, 93005, 93010, 93040, G0403, G0404, G0405)
- Testosterone level testing (CPT codes 84403, 84404)
- Vitamin B serum testing (CPT codes 82607, 82608)
- Albumin (urine) testing (CPT codes 82043, 82044)
- Iron level testing (CPT code 83540)
- Chest x-rays (CPT codes 71010, 71020)
While the above listed diagnostic tests and screenings are not considered preventive or eligible under our members’ wellness benefits, if our member/your patient has symptoms and a test is reasonable to help diagnose an illness, we believe the test should be provided. We’ll help inform our members about the difference between a wellness visit and an office visit associated with a specific condition. We’re also asking you to help our members understand when the services being provided them are no longer part of a wellness visit and may become their financial responsibility.
If you provide a non-USPSTF recommended test or screening at the same time the member is being seen for a wellness visit, please explain to them the service isn’t considered as preventive, and it may be billed separately from the wellness visit and/or will be an out-of-pocket cost. Members may have additional questions about their specific coverages for preventive and non-preventive care, as well as their cost-share amounts, and we ask that you refer them to our customer service team at the phone numbers listed on the back of their identification card.
Additional information about wellness benefits and the allowed USPSTF Approved Tests and Screenings is available in these FAQs.