|Possible Procedure/HCPCS Codes||Coverage||Patient Criteria||Patient Financial Responsibility||Provider Criteria||Possible Diagnosis Codes|
|Screening Pelvis Examination|
|G0101||Every 2 years||Not high risk||20 % allowable No Part B deductible||None stated||V76.2, V76.47, V76.49, V72.31|
|Collection of Pap Smear Specimen|
|Q0091||Every 2 years||Not high risk||20 % allowable No Part B deductible||None stated||V76.2, V76.47, V76.49, V72.31|
|82270 G0328||Annually||>50 years old||None||None stated||V76.51, V76.41|
|77057, +77052 G0202||Annually||>40 years old||20 % allowable No Part B deductible||None stated||V76.12, V76.11|
|Screening Bone Mass Measurement|
|77078, 77079, 77080, 77081, 77083, 76977, G0130||Once every 24 months||Patients at risk||20% allowable Deductible applies||Test ordered by physician or qualifed non physician practitioner who is treating patient.||Determined by Local Carriers*|
|Initial Preventive Physical Examination (Welcome to Medicare Examination)|
|G0402, G0403, G0404, G0405||Once||Within first 12 months of Medicare coverage||20% allowable Deductible waived, but co-insurance provision apply||Test ordered by physician or qualifed non physician practitioner who is treating patient.||V070.0|
|82947, 82950, 82951||Twice in 12 month period||Patients at risk||None||None stated||V77.1|
|Cardiovascular Screening Blood Test|
|82465, 84478, 83718, 80061||Every 5 years||All Medicare beneficiaries||None||Test must be ordered by physician and used in management of patient||V81.0, V81.1, V81.2|
|Tobacco Use Cessation Counseling|
|99406, 99407||2 cessation attempts in 12 month period (1 attempt=up to 4 sessions)||Patient has condition or is receiving treatment that is being adversely affected by tobacco use||20% allowable Deductible applies||Provided by a physician, physician assistant, nurse practitioner, clinical nurse specialist, qualified psychologist or clinical social worker||Use code indicating patient's condition or treatment affected by tobacco use|
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