Collective Bargaining Agreement

2012-2016

Section 33 -- Benefits: Attachment A

Preventive Health Care and Immunization Guide for Children Birth - 18 Years

Preventive Services Birth to 1 Year 1 thru 4 Years 5 thru 12 Years 13 thru 18 Years
Schedule of Office Preventive Visits
  • Within first 2 weeks
  • 2 months
  • 4 months
  • Between 6-9 months
  • 15 months
  • 2 years
  • Once between 3-4 years
  • 5 years
  • Once between
    7-9 years
  • 12 years
  • Once between
    13 - 18 years
Components of Preventive Visits
  • Physical & medical history
  • Height & weight
  • Head Circumference
  • Ocular prophylaxis (typically given at birth)
  • Hemoglobin blood test
  • Preventive health couseling & education
  • Dental health
  • Subjective assessment of vision & hearing
  • Developmental screening
  • Injury prevention
  • Physical & medical history
  • Height & weight
  • Preventive health counseling & education
  • Dental health
  • Vision screen 3-4 years
  • Subjective assessment of hearing
  • Developmental screening
  • Blood pressure
  • Injury prevention
  • Physical and medical history
  • Height & weight
  • Preventive health counseling and education
  • Dental health
  • Vision screen
  • Hearing screen
  • Blood pressure
  • Injury prevention
  • Physical & medical history
  • Height & weight
  • Preventive health counseling and education
  • Dental health
  • Blood pressure
  • Injury prevention


Preventive Visits for children from birth to age 18 do not include tests and lab work ordered by the physician except for a hemoglobin blood test (CPT Code 85022) for children from birth to age 1 as shown above. The covered expense for Preventive Visits is the Reasonable and Customary charge for the following CPT Codes and includes the components shown above.

Age Birth to 1 99381 or 99391
1 thru 5 99382 or 99392
5 thru 12 99383 or 99393
12 thru 17 99384 or 99394
18 99385 or 99395

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Preventive Health Care and Immunization Guide for Children Birth - 18 Years - continued

Vaccine
Birth
2 Months
4 Months
6 Months
12 Months
15 thru 18 Months
4 thru 6 years
12 thru 16 years
DtaP (Diphtheria, Tetanus, Acellular Pertussis) CPT Code 90700, 90721, or 90723 (all except 12 to 16)   X X X   X X Adult Td (Tetanus, Diphtheeria)
X
CPT Code 90718
OPV (Oral Polio Vaccine) CPT Code 90712   X X 6 to 15 months
X 		X  
Hib (Haemophlus influenza b) CPT Code 90645, 90646, 90647, or 90648   X X X 12 to 15 months
X 		   
MMR (Measles, Mumps, Rubella) CPT Code 90707 or 90716         12 to 15 months
X 		  Booster between 11th to 12th year
X
Varicella (Chicken Pox) CPT Code 90716         12 to 15 months
X 		  Booster between 11th to 12th year
X
HV (Hepatitus B) CPT Code 90740, 90743, or 90744 X 2 to 4 months
X 		6 to 18 months
X 		  X

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Preventive Health Care Guide for Adults

Preventive Services Ages 19 thru 49 Ages 50 thru 54 Ages 55 and Over
Adult physical examination ** Every 5 years Every 2 years 1 per calendar year
Blood pressure check CPT Codes 99201 or 99211 Every 2 years Every 2 years 1 per calendar year
Blood cholesterol (Total and HDL) CPT Code 83715, 83718 or 82465 Every 5 years Every 2 years 1 per calendar year
Complete Blood Count (CBC) CPT Code 85025 Every 5 years Every 2 years 1 per calendar year
Chemistry Panel CPT Code 80048 Every 5 years Every 2 years 1 per calendar year
Hemoccult CPT Code 82270   Every year beginning at age 50 Every year
Flexible sigmoidoscopy or colonoscopy CPT Code 45330 or 45378   Every 5 years beginning at age 50 Every 5 years
Vision Screening CPT Code 99173     Every 1-2 years beginning at age 75
Tetanus-diphtheria (Td)vaccine CPT Code 90471, 90472, or 90718 Every 10 years Every 10 years Every 10 years
Influenza vaccine CPT Code 90657, 58, 59 or 60     1 per calendar year
Pneumococcal vaccine CPT Code 90732     Once after age 65
Rubella CPT Code 86762 or 90706 Once in lifetime Once in lifetime Once in lifetime

** Adult Physical Exam does not include tests and lab work ordered by the physician unless the test or lab work is specifically listed above. The covered expense for an Adult Physical Exam is the Reasonable and Customary charge for the following CPT Codes and includes the customary services performed by a Physician in an adult physical examination, including but not limited to assessment and history and vision screening.

Ages 18 to 39 —— 99385 or 99395
40 to 64 —— 99386 or 99396
65 plus —— 99387 or 99397

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