Effective April 1, 2022, Blue Cross and Blue Shield of Illinois (BCBSIL) has announced updates to Preventive Services Policy to help ensure accurate coding of services and that services are properly reimbursed.
Preventive care refers to measures or services taken to promote health and early detection/prevention of disease(s) and injuries rather than treating them and/or curing them.
Certain preventive care services may be considered eligible for coverage under the member’s benefit plan as required by Patient Protection and Affordable Care Act (PPACA) and/or an applicable state mandate.
In order for preventive claims to process at the preventive level with no member cost share, the claim must include a preventive diagnosis code, a preventive procedure code, meet medical policy review criteria, and fall within the guidelines issued by the United States Preventive Services Task Force, Advisory Committee on Immunization Practices, Health Resources and Services Administration, or Bright Futures.
For instance, the following is an example of Fall Prevention recommendation released by the USPSTF, ACIP, HRSA, or Bright Futures along with the corresponding procedure codes and diagnosis codes deemed to be preventive.
Services - Falls Prevention in Community-Dwelling Older Adults: Interventions USPSTF “B” Recommendation April 2018 The USPSTF recommends exercise interventions to prevent falls in community-dwelling adults aged 65 years or older who are at increased risk for falls.
Providers Procedure Codes - 97110, 97112, 97116, 97150, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, and 97530.
Additional Reimbursement Criteria - 97110, 97112, 97116, 97150, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, and 97530 reimbursable with a diagnosis of Z91.81.
Stay tuned for our future announcements.