Description 
The Federal Patient Protection and Preventive Care Act (PPACA) was passed by Congress and signed into law by the president in March 2010. The preventive services component of the law became effective Sept. 23, 2010. A component of the law was a requirement that all “non-grandfathered” health insurance plans are required to cover those preventive medicine services given an “A” or “B” recommendation by the U.S. Preventive Services Task Force (USPSTF).

Plans are not required to provide coverage for the preventive services if they are delivered by out-of-network providers.

Task Force recommendations are graded on a five-point scale (A – E), reflecting the strength of evidence in support of the intervention. Grade A: There is good evidence to support the recommendation that the condition be specifically considered in a periodic health examination. Grade B: There is fair evidence to support the recommendation that the condition be specifically considered in a periodic health examination. Grade C: There is insufficient evidence to recommend for or against the inclusion of the condition in a periodic health examination, but recommendations may be made on other grounds. Grade D: There is fair evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination. Grade E: There is good evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.

Those preventive medicine services listed as Grade A & B recommendations are covered without cost sharing (i.e., deductible, coinsurance or copayment) by health plans for appropriate preventive care services provided by an in-network provider. If the primary purpose for the office visit is for other than Grade A or B USPSTF preventive care services, deductible, coinsurance or copayment may be applied.

Services are typically included as part of a normal wellness visit; the appropriate office visit code should be used. Evaluation and Management codes for preventive services 99381 – 99397 will always be considered preventive. CPT codes 99401 – 99404, when used to designate a preventive service, must have the applicable wellness/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 U.S. Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’.

The correct coding as listed for both ICD-9 and CPT or HCPCS codes in this summary is also required along with Modifier 33. CPT Codes Copyright © 2011 American Medical Association.

Subject to change as regulations and further clarifications are received.

NOTE: THIS POLICY APPLIES ONLY TO NON-GRANDFATHERED PLANS.

Policy: 
BACTERIURIA, SCREENING IN PREGNANT WOMEN