Medicare Lab Screening Benefits

The Medicare Program covers preventive screening tests for cardiovascular disease, diabetes, colorectal cancer, HIV infection, prostate cancer, STD’s & hepatitis C.

Patient Eligibility and Diagnosis Requirements

SCREENING TEST ORDERED HCPCS/CPT CODES COVERED ICD-10 CODES WHO IS ELIGIBLE FREQUENCY

Cardiovascular Disease

80061-lipid panel

Must include cholesterol

(82465),lipoprotein (83718)and

triglycerides (84478)

Z13.6

*All beneficiaries

1 every 5 years

Colorectal Cancer

G0328

82270

ST IOB 1MS or 70765326

Z12.11 and Z12.12

*Ages 50-85

*Asymptomatic

*At risk for developing colorectal cancer

Annually

Diabetes

82947-Glucose-quant

82950-Glucose-post dose

82951 Glucose-GTT

Z13.1

*At risk for diabetes

*Diagnosed with pre-diabetes

*2 times per year for pre-diabetic

*Annually if not pre-diabetic

Hepatitis C Virus (HCV)

G0472

HCV MS or 70999999

Z72.89 or F19.20

Z11.59 for those in the 1945-1965 age range

*High risk for HCV infection

*Born between 1945-1965

*Annually for high risk

*1 lifetime for those born between 1945-1965

HIV

G0433

HIV MS or 69991446

No risk factors – Z11.4

Risk factors – add Z72.89,Z72.51,Z72.52 or Z72.53

Pregnancy-Z11.4 plus Z34.00, Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82, Z34.83, Z34.90, Z34.91, Z34.92, Z34.93, O09.90, O09.91, O09.92, or O09.93

*Increased risk for HIV

*Pregnant women

*Annually for those between ages of 15-65 w/out regard to risk

*Annually for patients younger than 15 or older than 65 with increased risk.

*3 times per pregnancy

-at diagnosis

-third trimester

-at labor

Prostate Cancer

G0103

PSA MS or 70999206

Z12.5 

Males over 50

Annually

Sexually Transmitted Infections

86631, 86632, 87110, 87270, 87320, 87490, 87491, 87810 – Chlamydia

87590, 87591, 87850 - Neisseria gonorrhoeae

87800 - Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s) technique

86592 - Syphilis test, non-treponemal antibody; qualitative (e.g., VDRL, RPR, ART)

86593 - Syphilis test, non-treponemal, quantitative

86780 - Treponema pallidum

Z11.3, Z72.89, Z72.51, Z72.52, Z72.53, Z34.00, Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82, Z34.83, Z34.90, Z34.91, Z34.92, Z34.93, O09.90, O09.91, O09.92, and O09.93

When all is true:

*sexually active with increased risk

*referred and provided by Medicare eligible PCP

Annually for chlamydia, gonorrhea, and syphilis in women at increased risk and not pregnant

Annaully for syphilis in men at increased risk

Twice per pregnancy for chlamydia and gonorrhea for women with increased risk and continued risk to 2nd trimester

Once per pregnancy for syphilis in pregnant women; up to two additional occurrences in the third trimester and at delivery if at continued increased risk for STIs

Hepatitis B

G0499

HBV MS or 70900031

86704 - Hep B core antibody

86706 - Hep B surface antibody

87340 - Hep B surface antigen

87341 - Hep B surface antigen neutralization

no screen CPT needed for these patients

Must have both Z11.59 AND Z72.89

No risk: Z11.59 and Z34.00 or Z34.80 or Z34.90 or O09.90

At risk: Z11.59 and Z72.89 and one of the following:

Z34.00-Z34.03

Z34.80-Z34.83

Z34.90-Z34.93

O09.90-O09.93

High risk, asymptomatic non-pregnant adolescents and adults

Pregnant beneficiaries

Annually as long as the risk continues.