Affordable Care Act: Preventive Care A guide to preventive benefits for nongrandfathered plans This document provides a detailed outline of the services approved as preventive under the Affordable Care Act.
What the Law Requires The Affordable Care Act (ACA), or Health Care Reform law, requires non-grandfathered plans to cover certain preventive care services at no cost sharing when members use in-network providers. The United States Preventive Services Task Force (USPSTF) A and B recommendations describe these recommended preventive services. We based immunization guidelines on those from the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC), and Health Resources and Services Administration (HRSA) guidelines, including the American Academy of Pediatric Bright Futures recommendations. These are independent organizations that provide health information on behalf of BlueCross BlueShield of South Carolina and BlueChoice HealthPlan. Who Does It Impact The preventive services provisions of the law apply to non-grandfathered health plans. These include both individual health plans and employer-sponsored (group) health plans. A non-grandfathered plan is one that took effect after the government enacted the law on March 23, 2010. A grandfathered health plan is one that was in effect before this date. A plan remains grandfathered as long as it does not significantly reduce benefits or increase out-of-pocket spending above what it was when the government enacted the new law. When Does It Take Effect The preventive services provision took effect for non-grandfathered plans for plan years on or after September 23, 2010. Coverage for additional women s preventive services took effect for plan years on or after August 1, 2012. As services are added or updated, health plans must begin to provide coverage consistent with the recommendation. They must take effect in the first plan or policy year that begins on or after one year after the recommendation went into effect. 1
Providing Services and Billing There may be times when a patient who receives recommended preventive care still must pay an out-of-pocket amount for the associated office visit. For instance, how you bill and code the preventive service either separately from the office visit or with the office visit can dictate whether there is a patient liability or not. The primary purpose of the office visit will also determine if there will be an out-of-pocket amount associated with the care. If you bill the preventive service separately from the office visit, we may require the patient to pay the usual cost-sharing (deductible, coinsurance or copayment) amount for the office visit but not the recommended preventive service. This may occur regardless of the primary purpose for the office visit. If you include the recommended preventive care service with the office visit, then the primary purpose of the office visit must be preventive in nature. If the primary purpose of the office visit is to get the recommended preventive care service, the patient does not have to pay for the office visit or preventive care service. For example, if a child receives a wellchild exam and immunizations and the primary purpose of the visit was preventive care, the patient will not have any liability for the immunizations or exam. If the primary purpose of the office visit is for something other than the recommended preventive care service, you may charge the patient the usual cost-sharing amount (deductible, copayment or coinsurance) for the office visit. For example, if a child receives an exam for a complaint (sore throat, cough, etc.) and also receives immunizations, there may be an out-of-pocket expense for the exam but not the immunizations. If you provide services that aren t included in this guide, be sure to bill the services with a diagnosis that s appropriate for the exam or service. Otherwise, we may not cover the services. Services are typically included as part of a normal wellness visit. Use the appropriate office visit code. We consider evaluation and management codes 99381-99397 to be preventive. Codes 99401-99404, when used to designate a preventive service, must have the applicable wellness or preventive diagnosis code as the primary reason for the visit. When the primary purpose of the service is the delivery of an evidence-based service in accordance with a USPSTF A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), you can bill the service with modifier -33. Please note use of the 33 modifier with specific surgical codes will help identify the procedure as preventive. For More Information This document provides an overview of these services. You should also visit the appropriate websites (listed throughout this document) for more details. You can also visit www.healthcare.gov for more information. To learn more about grandfathered versus non-grandfathered plans, go to: www.healthcare.gov/what-if-i-havea-grandfathered-health-plan If you have questions, contact Provider Education at 803-264-4730 or email at Provider.Education@bcbssc.com. 2
Preventive Services USPSTF A and B Recommendations To read more about these services, please visit http://www.uspreventiveservicestaskforce.org/browserec/index/browse-recommendations. Please keep in mind that services may be added to this list or changed. When that occurs, health plans must begin to provide coverage consistent with the recommendation in the first plan or policy year that begins on or after one year after the recommendation went into effect. Recently added or updated services are in the footnotes with their effective dates. Test Patient Criteria Other Information CPT/HCPCS Abdominal aortic One time for men ages 65-75 aneurysm (AAA) 1 who have ever smoked. Alcohol misuse counseling and/or Aspirin to prevent cardiovascular disease Bacteriuria BRCA testing, risk assessment genetic counseling /testing 2 Adults ages 18 years or older for alcohol misuse. Men ages 45 to 79 years. Women ages 55 to 79 years. Pregnant women at 12 to 16 weeks gestation or at the first prenatal visit, if later. Women who have family members with breast, ovarian, tubal or peritoneal cancer. For persons engaged in risky or hazardous drinking, provide brief behavioral counseling interventions to reduce alcohol misuse. Recommend when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage. Use one of several tools to identify if there is a family history that may be associated with an increased risk for potentially harmful mutations in breast cancer susceptibility genes (BRCA1 or BRCA2). Examples of tools include, but are not limited, to: Ontario Family Health Assessment tool Manchester Scoring System Referral Screening tool Pedigree Assessment tool G0389 99408 G0396 G0443 87086 99385-99387 99395-99397 81211-81217 96040 S0265 Diagnosis (ICD-9) V15.82 V81.2 V79.1 V22.0 V22.2 V23.0 V23.9 V16.3 V16.40 V16.41 V26.33 Women with positive results should receive genetic counseling. If indicated after counseling, provide BRCA testing. 3
Breast cancer, preventive medication 3 Test Patient Criteria Other Information CPT/HCPCS Breast cancer (mammography) Breastfeeding counseling Women who are at increased risk for breast cancer and are at low risk for adverse medication effects. Women with or without clinical breast examination, every one - two years for women ages 40 and older. During pregnancy and after birth to promote and support breastfeeding. Educate women about medications to reduce their risk. Clinicians should offer to prescribe risk-reducing medications, such as tamoxifen or raloxifene. Examples of tools include, but are not limited, to: Ontario Family Health Assessment tool Manchester Scoring System Referral Screening tool Pedigree Assessment tool Our medical policy, CAM 046, also addresses breast pumps. It indicates we allow these two breast pumps for members who qualify with no cost sharing: Ameda Purely Yours electric pump Ameda One Hand Manual pump 99401-99404 77052 77057 G0202 99401 99402 Diagnosis (ICD-9) V16.3 V84.01 V76.10 V76.11 V76.12 V22.0-V24.2 V24.1 Cervical cancer Women ages 21 to 65 years. Women ages 30 to 65 years who want to lengthen the interval. Cytology (Pap smear) every three years. Screening with a combination of cytology and human papillomavirus (HPV) testing every five years. 88141-88154 88164-88167 88174-88175 G0101 G0123-G0124 V72.3 V72.31 V72.32 V76.2 Chlamydia infection (women and adolescents) Colorectal cancer * All sexually active nonpregnant young women ages 24 and younger. Also for older, non-pregnant women who are at increased risk. All pregnant women ages 24 and younger. Also for older, pregnant women who are at increased risk. Adults, beginning at age 50 and continuing until age 75. Screening methods include: Fecal occult blood testing Sigmoidoscopy Colonoscopy The risks and benefits of these methods vary. 87490 87491 00810 45330-45349 45378-45392 82270 82274 G0104 G0106 G0122 G0328 V73.88 V73.98 V76.41 V76.51 4
Dental caries (preschool children 4 ) Test Patient Criteria Other Information CPT/HCPCS Depression (adults) Depression (adolescents) Diabetes mellitus Type 2 (adults) Diabetes mellitus (pregnant women 5 ) Fall prevention (communitydwelling, older adults) Folic acid, prevention of neural tube defects Gonorrhea prophylaxis Gonorrhea Hearing loss All infants and children starting at the age of primary tooth eruption. Children at age 6 months whose water supply is fluoride deficient. Adults. Adolescents ages 12-18. Asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg. Asymptomatic pregnant women, 24-28 weeks of gestation and at the first prenatal visit for pregnant women identified as high risk for diabetes. Community-dwelling adults ages 65 or older who are at increased risk for falls. All women planning or capable of pregnancy. Newborns. All sexually active women, including those who are pregnant. Newborn infants (less than 1 month of age). Apply fluoride varnish to the primary teeth in primary care practices. Primary care clinicians should prescribe oral fluoride supplementation. Screen when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment and follow up. Screen for major depressive disorder (MDD) when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal) and follow up. Provide exercise or physical therapy and vitamin D supplementation to prevent falls. Recommend they take a daily supplement containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid. Not routinely covered for all women capable of pregnancy. Provide prophylactic ocular topical medication against ophthalmia neonatorum. Screen for gonorrhea infection if they are at increased risk for infection (i.e., if young or have other individual or population risk factors). After the 4th month, if there are positive responses to risk questions, refer the infant for diagnostic audiologic assessment. 99188 D1208 99420 G0444 99420 G0444 82947 82948 82947 82948 82950 97001 97002 97110 97116 97750 A9152 87590 87591 87850 92558 92586 Diagnosis (ICD-9) V79.0 V79.0 V77.1 V22.0-V22.2 V23.0-V23.9 V77.1 V15.88 V65.41 V65.43 V20.2 V70.0 V72.3 V72.31 V22.0-V24.2 V30-V39 5
Test Patient Criteria Other Information CPT/HCPCS Hepatitis B virus (HBV) (non-pregnant adolescents and adults 6 ) HBV (pregnant) Hepatitis C virus (HCV) High blood pressure HIV counseling and Hypothyroidism Non-pregnant adolescents and adults at high risk for infection. Pregnant women at their first prenatal visit. Persons at high risk for infection. Offer a one-time for HCV infection to adults born between 1945 and 1965. Adults ages 18 and older. Adolescents and adults ages 15-65 years. Younger adolescents and older adults who are at increased risk. All pregnant women, including those who present in labor who are untested and whose HIV status is unknown. In addition, CDC guidance for high risk for infection includes: Persons born in geographic regions with HBsAg prevalence of >2% US-born persons not vaccinated as infants whose parents were born in geographic regions with HBsAg prevalence of >8% Injection drug users Men who have sex with men Persons with elevated ALT/AST of unknown etiology Persons with selected medical conditions who require immunosuppressive therapy Pregnant women Infants born to HBsAg-positive mothers Household contacts and sex partners of HBV-infected persons Persons who are the source of blood or body fluid exposures that might warrant postexposure prophylaxis (e.g., needlestick injury to a health care worker) Persons infected with human immunodeficiency virus (HIV) 80055 87340 80055 87340 86803-86804 99385-99387 99395-99397 V81.1 86703 87389 87390 G0432 G0433 Newborns. 84443 V77.0 Diagnosis (ICD-9) V22.0 V22.2 V23.0 V23.9 V28.9 V01.79 V22.0 V24.2 6
Test Patient Criteria Other Information CPT/HCPCS Intimate partner violence /counseli ng of women, annually Iron deficiency anemia Iron supplementation Lipid (cholesterol) Lung cancer, adults 7 Nutrition (dietary) counseling, adults Obesity in adults and children ages 6 or older, and counseling Osteoporosis Women of childbearing age. Asymptomatic pregnant women. Asymptomatic children ages 6 to 12 months who are at increased risk for iron deficiency anemia. Men ages 35 and older for lipid disorders. Men ages 20 to 35 for lipid disorders if they are at increased risk for coronary heart disease. Women ages 45 and older for lipid disorders if they are at increased risk for coronary heart disease. Women ages 20 to 45 for lipid disorders if they are at increased risk for coronary heart disease. Adults ages 55-80 years who have a 30 pack-per-year smoking history and currently smoke or have quit within the past 15 years. Adults who are overweight or obese and have additional cardiovascular disease (CVD) risk factors. Effective June 2012: All adults with a body mass index (BMI) of 30 kg/m2 or higher. Women ages 65 and older and younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors. Screen for intimate partner violence, such as domestic violence, and provide or refer women who screen positive to intervention services. This recommendation applies to women who do not have signs or symptoms of abuse. Screen annually for lung cancer with low-dose computer tomography. You should discontinue once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery. Offer or refer them to intensive behavior counseling interventions to promote a healthy diet and physical activity for CVD prevention. Offer or refer patients to intensive, multicomponent behavioral interventions. 99401 99402 and 99404 require review of records. 80055 85013 85014 85018 Diagnos is (ICD- 9) V61.11 V22.0 V23.9 V20.2 80061 V77.91 71250 (with modifier 52) S8032 (effective 10/01/2014) 97802 97804 G0270 S9470 99401 99402 G0447 V76.0 V65.3 V77.8 77080 V82.81 7
Test Patient Criteria Other Information Phenylketonuria (PKU) Rh incompatibility Sexually transmitted infections (STIs), behavioral counseling to prevent Skin cancer counseling Sickle cell disease Syphilis Tobacco use,, counseling and interventions 8 Visual impairment *Use of the 33 modifier with specific surgical codes will help identify the procedure as preventive. CPT/HCPC S All newborns. 84030 V77.3 All pregnant women during their first visit for pregnancyrelated care. All unsensitized Rh (D)- negative women at 24-28 weeks gestation, test for repeated Rh (D) antibodies unless the biological father is known to be Rh (D)-negative. All sexually active adolescents and adults at increased risk for STIs. Children, adolescents and young adults ages 10 to 24 who have fair skin. Newborns. All persons at increased risk for syphilis infection. All pregnant women. All adults. All pregnant women. School-aged children. All children between the ages of 3 and 5. Offer high-intensity behavioral counseling to prevent STIs. Counsel about minimizing their exposure to ultraviolet radiation to reduce risk for skin cancer. Ask about tobacco use and provide tobacco cessation interventions for those who use tobacco products. Ask about tobacco use and provide augmented, pregnancy-tailored counseling for those who smoke. Provide interventions, including education or brief counseling, to prevent initiation of tobacco use. Visual by a non-eye care professional, at least once, to detect the presence of amblyopia or its risk factors. 80055 86901 99401 99402 Coverage at no cost share for these footnoted services take effect for plan or policy years that begin on or after these dates: Diagnosis (ICD-9) V22.0 V23.9 V65.44 V65.45 V69.2 99401 V65.43 83020 83021 80055 86592 86780 99406 99407 99173 99174 V30-V30.9 V78.2 V22.0 V23.9 V69.2 V74.5 305.1 649.01-649.04 V15.82 V15.89 V80.2 1. 2. 3. 4. June 20, 2015 December 24, 2014 September 24, 2014 May 31, 2015 5. 6. 7. 8. January 14, 2015 May 31, 2015 December 31, 2014 August 27, 2014 8
Additional Preventive Services Children To view or download a PDF of the Bright Futures/American Academy of Pediatrics Coding Guide for Preventive Pediatric Care, visit brightfutures.aap.org/pdfs/coding%20pr%20f0809.pdf Medical History Measurements Length/height and weight Head circumference Weight for length Body mass index Blood pressure Sensory Screening Vision Hearing Developmental/Behavioral Assessments Developmental Autism Developmental surveillance Psychosocial/behavioral assessments Alcohol and drug use assessment Physical Exam Procedures Newborn metabolic/hemoglobin Immunizations Hematocrit or hemoglobin Lead Tuberculin test Dyslipidemia STI prevention counseling and Cervical dysplasia Oral Health 1
Child Immunizations To read more about the recommended immunizations for infants, children and teens, including the dosing schedules by specific age, please visit www.vaccines.gov/who_and_when/infants_to_teens/index.html The U.S. Department of Health and Human Services is an independent organization that provides health information on behalf of BlueCross BlueShield of South Carolina and BlueChoice HealthPlan. Birth to 15 Months Hepatitis A Hepatitis B Rotavirus Diphtheria, Tetanus, Pertussis Haemophilus influenza type b Pneumococcal Inactivated poliovirus Influenza Measles, Mumps, Rubella Varicella Meningococcal 18 Months to 18 Years Hepatitis A Hepatitis B Tetanus, Diphtheria, Pertussis Human Papillomavirus Meningococcal Influenza Pneumococcal Inactivated Poliovirus Measles, Mumps, Rubella Varicella In addition to these recommendations, there are also catch-up recommendations for children who fall behind or start late with their immunizations. To see those recommendations, please visit www.vaccines.gov/who_and_when/child/index.html Adult Immunizations To read more about the recommended immunizations for adults, including the dosing schedules by specific age and group, please visit www.vaccines.gov/who_and_when/adults/index.html Adults (Age 19 and Over) Tetanus, Diphtheria, Pertussis Human papillomavirus Varicella Zoster Measles, Mumps, Rubella Influenza Pneumococcal Hepatitis A Hepatitis B Meningococcal Haemophilus influenza type b 10
January 2015 IMPORTANT NOTICE This document is provided for informational purposes only and does not constitute legal advice or legal opinions. BlueCross BlueShield of South Carolina makes no representations regarding the accuracy or legal effect of the information contained herein, and disclaims any warranty of any kind related to it. This document may be based on internal interpretations of health care reform legislation, is subject to change without notice, and is not a substitute for legal advice from your lawyers. 11