Preventive Services and Chronic Disease Management

Updated: October 2026

Purpose

Preventive care is a key component to member wellness. North Dakota Medicaid covers preventive services including many A and B grade recommendations from the United States Preventive Services Task Force (USPSTF), recommended immunizations by the Advisory Committee on Immunization Practices (ACIP), and Bright Futures/American Academy of Pediatrics (AAP) recommendations. 

Applicability

Eligible Providers

To receive payment from ND Medicaid, the eligible servicing and billing providers must be enrolled with ND Medicaid on the date of service, and their National Provider Identifiers (NPIs) must be active in their Medicaid enrollment records. Servicing providers acting as a locum tenens provider must be enrolled with ND Medicaid, and services they provide must be billed with their NPI. Please refer to provider enrollment for additional details on enrollment eligibility and supporting documentation requirements.

Eligible Members

Providers are responsible for verifying a member’s eligibility before providing services. Eligibility can be verified using the ND Medicaid MMIS Portal or through the Automated Voice Response System by dialing 1.877.328.7098.

Refer to the Member Eligibility Manual for additional information regarding eligibility including information regarding limited coverage categories. 

Covered Services and Limits

General Provider Policies

The General Provider Policies details basic coverage requirements for all services. Basic coverage requirements include:

• The provider must be enrolled in ND Medicaid;
• Services must be medically necessary;
• The member must be eligible on the date of service; and
• If applicable, the service has an approved service authorization. 

The Procedure Code Look-up Tool can be used to identify if a procedure code is covered by ND Medicaid, along with code specific details such as ORP requirements, Service Authorization requirements, and current rates. 

Preventive Medical Services

Staying current with recommended wellness visits is key to early prevention and treatment of health issues. Preventive medicine services are comprehensive and relate to the age of the patient.

Components of a preventive medical visit include:

• Comprehensive history and physical exam findings; and
• Age-appropriate:
  • Counseling/anticipatory guidance/risk factor reduction interventions; and
  • Screening labs and tests.

Preventive visits have no major complaint or illness as their focus and providers must complete a comprehensive:

• System review;
• Past, family, and social history;
• Assessment; and
• History of pertinent risk factors.

These components differ from a problem-focused exam because they are based on the patient’s age and risk factors.

A small or unimportant problem or abnormality that comes up during a preventive medicine evaluation and management (E/M) service should not be reported unless it requires:

• additional work; and
• the performance of key components of a problem-oriented E/M service.

Wellness Visit Codes:

9938X/9939X - new or established wellness exam– comprehensive preventive medicine evaluation and management service

Well Adult Visits

Preventive services performed at adult annual wellness visits vary based on the patient’s age and risk factors. Visits may include:

• Cancer screenings:
  • Breast cancer screening (mammogram);
  • Cervical cancer screening (women ages 21-65);
  • Colorectal cancer screening (adults ages 45-75);
  • Lung cancer screening (adults ages 50-80 with history of smoking); and
  • Skin cancer prevention.
• Screenings for chronic conditions including:
  • Abdominal aortic aneurysm screening (men 65-75 who have ever smoked);
  • Depression screening and follow-up plan;
  • Hepatitis B infection screening (adults at risk of increased infection);
  • Hepatitis C screening (adults ages 18-79);
  • Hypertension/High blood pressure screening;
  • Latent Tuberculosis (TB) infection screening (adults at increased risk);
  • Osteoporosis screening (women ages 65+, high risk women <60);
  • Prediabetes and Type 2 Diabetes screening (adults 35-70 who are overweight or obese); and
  • Statin use for prevention of cardiovascular disease (adults ages 40-75)
• Health promotion and education including:
  • Fall prevention in older adults (ages 65+);
  • Healthful diet and physical activity for cardiovascular disease counseling;
  • Tobacco use cessation interventions;
  • Intimate partner violence screening and counseling;
  • Unhealthy drug and/or alcohol use screening and behavioral counseling interventions; and
  • Screening for anxiety
• Reproductive health screening and education including:
  • Chlamydia and Gonorrhea screening (sexually active women 24 and younger, older women at risk);
  • Contraceptive services and counseling, including postpartum women;
  • Human immunodeficiency virus (HIV) screening (adults ages 21-65 and others at increased risk);
  • Sexually Transmitted Infections (STI) counseling (adults at high risk; all sexually active women); and
  • Syphilis screening (adults at increased risk).

• Pregnancy & postpartum screenings and education including:
  • Breastfeeding services and supplies;
  • Breastfeeding primary care interventions;
  • Folic acid supplement to prevent neural tube defects;
  • Healthy weight and weight gain in pregnancy, behavioral counseling interventions;
  • Interventions for tobacco smoking cessation;
  • Asymptomatic bacteriuria;
  • Depression:
    • Maternal depression screening (CPT© code 96161) performed in conjunction with a child’s wellness visit, or any other pediatric visit, as a risk assessment for the child anytime within the child’s first year. 
  • Gestational diabetes and diabetes mellitus after pregnancy;
  • Hepatitis B;
  • HIV;
  • Preeclampsia;
  • Rh(D) incompatibility; and
  • Syphilis.
• Well-Woman Care.
  • Recommendations for preventive health care screenings and services for well-woman visits can be found at the Women’s Preventive Services Initiative (WPSI).

Coverage for Colorectal Cancer Screening Services

Centers for Medicare and Medicaid Services identify a patient as high-risk for colorectal cancer if they have any of the following:

• A close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp;
• A family history of familial adenomatous polyposis;
• A family history of hereditary nonpolyposis colorectal cancer;
• A personal history of adenomatous polyps; or
• A personal history of colorectal cancer; or
• Inflammatory bowel disease, including Crohn’s disease and ulcerative colitis.

If during a screening colonoscopy or sigmoidoscopy, a lesion/growth is detected which results in biopsy/removal of growth, the appropriate diagnostic procedure classified as colonoscopy with biopsy/removal should be billed rather than the screening procedure. Diagnostic and therapeutic colonoscopies are also covered by ND Medicaid. 

If the results of a stool test are positive or abnormal, the member’s follow-up colonoscopy is part of the screening process and not a diagnostic procedure. 

Billing guidance applicable to all well-checks

Screenings with identified CPT® codes are separately billable from the well-check visit.

If an abnormality is encountered or a preexisting problem is addressed in the process of performing this preventive medicine E/M service, and if the problem or abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the appropriate Office/Outpatient CPT® code 99202-99215 should also be reported. Modifier -25 should be added to the Office/Outpatient code to indicate that a significant, separately identifiable E/M service was provided on the same day as the preventive medicine service. The appropriate preventive medicine service is additionally reported.

The provider’s electronic signature on the claim is the attestation of the medical necessity of both services, including an assurance that the following requirements are met. 

Requirements for providing Preventive and Focused Problem (E/M) care same day include: 

• Provider documentation must support billing of both services. Providers must create separate notes for each service rendered in order to document medical necessity. 
• In deciding on appropriate E/M level of service rendered, only activity performed “above and beyond” that already performed during a wellness visit is to be used to calculate the additional level of E/M service. If any portion of the history or exam was performed to satisfy the preventive service, that same portion of work should not be used to calculate the additional level of E/M service. 
• All elements supporting the additional E/M service must be apparent to an outside reader/reviewer. 
• The note documenting the focused E/M encounter should contain a separate history of present illness (HPI) paragraph that clearly describes the specific condition requiring evaluation and management. 
• The documentation must clearly list in the assessment the acute/chronic condition(s) being managed at the time of the encounter. 

Limits

• ND Medicaid will not reimburse HCPCS code S0302 – EPSDT screening, and CPT© code 9938x/9939x – Preventive Medicine Services on the same date of service.
• Adult wellness screenings are limited to one per calendar year.

Diabetes Self-Management and Training (DSMT) Services

DSMT services may be provided by pharmacists, licensed registered dieticians, and registered nurses with diabetic educator credentialing suing the following codes. 

• G0108 – Diabetes outpatient self-management training services, individual, per 30 minutes.
• G0109 – Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes.

Diabetic educator credentialed registered nurses are not ND Medicaid-enrollable providers for these services. This service is billed incident-to the licensed supervising practitioner.

Self-Monitoring Blood Pressure for Hypertension

Blood pressure self-monitoring may be ordered by a member’s physician, pharmacist or Other Licensed Practitioner. 

At-home self-monitored blood pressure monitoring may be medically necessary to:

• Differentiate between hypertension occurring due to being in the doctor’s office for the measurement (i.e. “white coat hypertension”); and 
• To help monitor variation in blood pressure measurements and appropriately adjust treatment protocols to avoid “overtreatment”. The second reason may result in more adherence to treatment.

Covered Services

Members must use a validated blood pressure device (CPT® A4670) from the Validated Device List – Blood Pressure Devices for blood pressure self-monitoring. ND Medicaid covers a one-time per monitor education and training on the set-up (CPT® code 99473) and use of a self-monitoring blood pressure (SMBP) measurement device, which includes device calibration.