Information is available for DOS before July 1, 2019.
Covered HealthCheck screening services are identified by the allowable procedures codes listed in the following tables.
| New Patient | ||
|---|---|---|
| Code | Description | Allowable Modifier |
| 99381 | Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; infant (age younger than 1 year) | UA |
| 99382 | early childhood (age 1 through 4 years) |
UA |
| 99383 | late childhood (age 5 through 11 years) |
UA |
| 99384 | adolescent (age 12 through 17 years) |
UA |
| 99385 | 18-39 years |
UA |
| Established Patient | ||
|---|---|---|
| Code | Description | Allowable Modifier |
| 99391 | Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; infant (age younger than 1 year) | UA |
| 99392 | early childhood (age 1 through 4 years) |
UA |
| 99393 | late childhood (age 5 through 11 years) |
UA |
| 99394 | adolescent (age 12 through 17 years) |
UA |
| 99395 | 18-39 years |
UA |
| Interperiodic Visits | ||
|---|---|---|
| Code | Description | Allowable Modifier |
| 99211 | Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services. | EP |
| 99212 | Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making.
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family. |
EP |
| 99213 | Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity.
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family. |
EP |
| 99214 | Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity (25 minutes)
Counseling and/or coordination of care with physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family. |
EP |
| 99215 | Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: a comprehensive history; a comprehensive examination; medical decision making of high complexity.
Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent face-to-face with the patient and/or family. |
EP |
| Environmental Lead Investigation (ELI) Services | ||
|---|---|---|
| Code | Description | Allowable Modifier |
| T1002 | Registered nurse services, up to 15 minutes | EP* |
| T1029 | Comprehensive environmental lead investigation, not including laboratory analysis, per dwelling | EP*, TS** |
*All claims for ELI services must include modifier EP in the first position.
**Modifier TS signifies follow-up service (for lead clearance investigation).
| Immunizations | |
|---|---|
| Code | Description |
| 906191 | Meningococcal conjugate vaccine, serogroups A, C, W, Y, quadrivalent, tetanus toxoid carrier (MenACWY-TT), for intramuscular use |
| 906321 | Hepatitis A vaccine (HepA), adult dosage, for intramuscular use |
| 906331 | Hepatitis A vaccine (HepA), pediatric/adolescent dosage-2 dose schedule, for intramuscular use |
| 906361 | Hepatitis A and hepatitis B vaccine (HepA-HepB), adult dosage, for intramuscular use |
| 906441 | Meningococcal conjugate vaccine, serogroups C & Y and Haemophilus influenzae B vaccine (Hib-MenCY), 4 dose schedule, when administered to children 6 weeks-18 months of age, for intramuscular use |
| 906471 | Haemophilus influenzae b vaccine (Hib), PRP-OMP conjugate, 3 dose schedule, for intramuscular use |
| 906481 | Haemophilus influenzae b vaccine (Hib), PRP-T conjugate, 4 dose schedule, for intramuscular use |
| 906491 | Human Papillomavirus (HPV) vaccine, types 6, 11, 16, 18, quadrivalent (4vHPV), 3 dose schedule, for intramuscular use |
| 906501 | Human Papillomavirus (HPV) vaccine, types 16, 18, bivalent (2vHPV), 3 dose schedule, for intramuscular use |
| 906551 | Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.25 mL dosage, for intramuscular use |
| 906561 | Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.5 mL dosage, for intramuscular use |
| 906571 | Influenza virus vaccine, trivalent (IIV3), split virus, 0.25 mL dosage, for intramuscular use |
| 906581 | Influenza virus vaccine, trivalent (IIV3), split virus, 0.5 mL dosage, for intramuscular use |
| 906601 | Influenza virus vaccine, trivalent, live (LAIV3), for intranasal use |
| 90661 | Influenza virus vaccine, trivalent (ccIIV3), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use |
| 906701 | Pneumococcal conjugate vaccine, 13 valent (PCV13), for intramuscular use |
| 906721 | Influenza virus vaccine, quadrivalent, live (LAIV4), for intranasal use |
| 90673 | Influenza virus vaccine, trivalent (RIV3), derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, for intramuscular use |
| 906801 | Rotavirus vaccine, pentavalent (RV5), 3 dose schedule, live, for oral use |
| 906811 | Rotavirus vaccine, human, attenuated (RV1), 2 dose schedule, live, for oral use |
| 906851 | Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.25 mL dosage, for intramuscular use |
| 906861 | Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5 mL dosage, for intramuscular use |
| 906881 | Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.5 mL dosage, for intramuscular use |
| 906961 | Diphtheria, tetanus toxoids, acellular pertussis vaccine and inactivated poliovirus vaccine (DTaP-IPV), when administered to children 4 through 6 years of age, for intramuscular use |
| 906981 | Diphtheria, tetanus toxoids, acellular pertussis vaccine, Haemophilus influenzae Type B, and inactivated poliovirus vaccine (DTaP-Hib-IPV), for intramuscular use |
| 907001 | Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), when administered to individuals younger than 7 years, for intramuscular use |
| 907021 | Diphtheria and tetanus toxoids (DT) adsorbed when administered to individuals younger than 7 years, for intramuscular use |
| 907071 | Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use |
| 907101 | Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use |
| 907131 | Poliovirus vaccine, inactivated (IPV), for subcutaneous or intramuscular use |
| 907141 | Tetanus and diphtheria toxoids adsorbed (Td), preservative free, when administered to individuals 7 years or older, for intramuscular use |
| 907151 | Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years or older, for intramuscular use |
| 907161 | Varicella virus vaccine (VAR), live, for subcutaneous use |
| 907231 | Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitis B, and poliovirus vaccine, inactivated (DtaP-HepB-IPV), for intramuscular use |
| 907321 | Pneumococcal polysaccharide vaccine, 23-valent (PPSV23), adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use |
| 907341 | Meningococcal conjugate vaccine, serogroups A, C, Y and W-135, quadrivalent, diphtheria toxoid carrier (MCV4 or MenACWY-D) or CRM197 carrier (MenACWY-CRM), for intramuscular use |
| 90740 | Hepatitis B vaccine (HepB), dialysis or immunosuppressed patient dosage, 3 dose schedule, for intramuscular use |
| 907431 | Hepatitis B vaccine (HepB), adolescent, 2 dose schedule, for intramuscular use |
| 907441 | Hepatitis B vaccine (HepB), pediatric/adolescent dosage, 3 dose schedule, for intramuscular use |
| 907461 | Hepatitis B vaccine (HepB), adult dosage, 3 dose schedule, for intramuscular use |
| 90747 | Hepatitis B vaccine (HepB), dialysis or immunosuppressed patient dosage, 4 dose schedule, for intramuscular use |
| 907481 | Hepatitis B and Haemophilus influenzae b vaccine (HepB-Hib), for intramuscular use |
| 90749 | Unlisted vaccine/toxoid |
| 90756 | Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, antibiotic free, 0.5 mL dosage, for intramuscular use |
| Laboratory Tests | |
|---|---|
| Code | Description |
| 810022 | Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy |
| 824653 | Cholesterol, serum or whole blood, total |
| 829473 | Glucose; quantitative, blood, (except reagent strip) |
| 850132 | Blood count; spun microhematocrit |
| 850182 | hemoglobin (Hgb) |
| 99000 | Handling and/or conveyance of specimen for transfer from the office to a laboratory |
| Other Tests/Assessments | |
|---|---|
| Code | Description |
| 86580 | Skin test; tuberculosis, intradermal |
| 96161 | Administration of caregiver-focused health risk assessment instrument (e.g., depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument |
1Vaccine is provided through the VFC Program. Procedure codes for vaccines available through the VFC Program are subject to change. Providers should refer to the VFC website for a complete list of vaccines available through the VFC Program.
2Service may be performed by HealthCheck agencies with an
approved CLIA waiver.
3Service may only be performed for high-risk children and requires
appropriate follow-up.