Coverage Policy Manual
Policy #: 2011022
Category: PPACA Preventive
Initiated: September 2010
Last Review: April 2018
  PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: CHLAMYDIAL INFECTION SCREENING IN WOMEN & ADOLESCENTS

Description:
The Federal Patient Protection and Preventive Care Act was passed by Congress and signed into law by the President in March 2010.  The preventive services component of the law became effective 23 September 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.  Additionally, the law requires coverage of Bright Futures recommendations for children from the American Academy of Pediatrics, preventive services for women outlined by the health Resources and Services Administration’s (HRSA’s) Women’s Preventive Services: Required Health Plan Coverage Guidelines and all vaccinations recommended by the Advisory Committee for Immunization Practices (ACIP) of the Centers for Disease Control and Prevention.
 
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, co-insurance, or co-pay) 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, co-insurance, or copay may be applied.
 
Bright Futures describes its guidelines as “evidence informed rather than fully evidence driven” (Hagan, 2008). Unlike the USPSTF, Bright Futures does not assign grades to recommendations that do not definitively recommend for or against a particular preventive service. Rather than leave gaps in the recommendations, Bright Futures supplements evidence with experience and expert opinion to ensure that definitive guidance is given (IOM, 2011).
 
The following policy is based on the USPSTF and Bright Futures recommendations for this preventive service.
 

Policy/
Coverage:
Effective August 2016
Screening for chlamydial infection is covered up to once per year (unless pregnant more than once) for members of “non-grandfathered” plans, without cost-sharing (i.e., deductible, co-insurance, or co-pay):
 
    • for all sexually active women aged 24 and younger and for older women who are at increased risk;
    • for adolescents aged 11- 21 years of age
 
The appropriate ICD-9 codes to report these services are V22.0-V22.2 , V23.0-V23.9 , V69.2, V70.0, V73.88, V73.98, V74.5 or V74.8.
 
The appropriate ICD-10 codes to report these services are Z33.1, Z34.00-Z34.93, O09-O09.40, O09.519, O09.529-O09.93, Z72.51-Z72.53, Z00.00, Z00.01, Z11.3, or  Z11.8.
 
The codes used for this service are 87270, 87320, 87490, 87491, 87800, 87801, and 87810.  When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US 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 are also required.
 
Effective April 2013-July 2016
Screening for chlamydial infection is covered up to once per year (unless pregnant more than once) for members of “non-grandfathered” plans, without cost-sharing (i.e., deductible, co-insurance, or co-pay):
 
    • for all sexually active non-pregnant young women aged 24 and younger and for older non-pregnant women who are at increased risk;
    • for all pregnant women aged 24 and younger and for older pregnant women who are at increased risk;  
    • for adolescents aged 11- 21 years of age
 
The appropriate ICD-9 codes to report these services are V69.2, V70.0, V74.5, V73.88 or V73.98; V22.0-V22.2 or V23.0-V23.9 (if pregnant).
 
The codes used for this service are 87270, 87320, 87490, 87491, 87800, 87801, and 87810.  When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US 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 are also required.
 
Effective prior to April 2013
Screening for chlamydial infection in women is covered up to twice per year for members of “non-grandfathered” plans, without cost-sharing (i.e., deductible, co-insurance, or co-pay):
 
    • for all sexually active non-pregnant young women aged 24 and younger and for older non-pregnant women who are at increased risk;
 
    • for all pregnant women aged 24 and younger and for older pregnant women who are at increased risk;
 
The appropriate ICD-9 codes to report these services are V69.2, V74.5, V73.88 or V73.98; V22.0-V22.2 or V23.0-V23.9 (if pregnant).
 
The codes used for this service are 87270, 87320, 87490, 87491, 87800, 87801, and 87810.  When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US 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 are also required.
 

Rationale:
The U.S. Preventive Services Task Force (USPSTF) recommends screening for chlamydial infection for all sexually active non-pregnant young women aged 24 and younger and for older non-pregnant women who are at increased risk (Grade A  recommendation).
 
The U.S. Preventive Services Task Force (USPSTF) recommends screening for chlamydial infection for all pregnant women aged 24 and younger and for older pregnant women who are at increased risk (Grade B recommendation).
 
 
The USPSTF recommendations include the following information:
Chlamydial infection is the most common sexually transmitted bacterial infection in the United States. In women, genital chlamydial infection may result in urethritis, cervicitis, pelvic inflammatory disease (PID), infertility, ectopic pregnancy, and chronic pelvic pain. Chlamydial infection during pregnancy is related to adverse pregnancy outcomes, including miscarriage, premature rupture of membranes, preterm labor, low birth weight, and infant mortality.
The USPSTF found fair evidence that nucleic acid amplification tests (NAATs) can identify chlamydial infection in asymptomatic  women, including asymptomatic pregnant women, with high test specificity. In low prevalence populations, however, a positive test is more likely to be a false positive than a true positive, even with the most accurate tests available.
      • Non-pregnant women at increased risk. There is good evidence that screening for chlamydial infection in women who are at increased risk can reduce the incidence of PID. The USPSTF concluded that the benefits of screening women at increased risk are substantial.
      • Pregnant women at increased risk. There are no studies evaluating the effectiveness of screening for chlamydial infection in pregnant women who are at increased risk. The USPSTF, however, found the following:
            1. Screening identifies infection in asymptomatic pregnant women.
            2. There is a relatively high prevalence of infection among pregnant women who are at increased risk.
            3. There is fair evidence of improved pregnancy and birth outcomes for women who are treated for chlamydial infection.
The USPSTF concluded that the benefits of screening pregnant women who are at increased risk are substantial.
      • Women not at increased risk. The USPSTF identified no studies documenting the benefits of screening women, including pregnant women, who are not at increased risk for chlamydial infection. While recognizing the potential benefit to women identified through screening, the USPSTF concluded the overall benefit of screening would be small, given the low prevalence of infection among women not at increased risk.
The USPSTF concluded that the harms of screening for chlamydial infection are no greater than small, although few studies have been published on this subject. Potential harms include anxiety and relationship problems arising from false positive results and over-treatment.
 
The USPSTF reached the following conclusions:
      • For non-pregnant women at increased risk, the certainty is high that the benefits of screening for chlamydial infection substantially outweigh the harms. This is a grade A Recommendation.
      • For pregnant women at increased risk, the certainty is moderate that the benefits substantially outweigh the harms of screening for chlamydial infection. This is a grade B Recommendation
 
 
The CDC recommends the following tests for screening for Chlamydia trachomatis: nucleic acid amplification tests (CPT 87491 or 87801), direct immunofluorescence (CPT 87270 or 87810), enzyme immunoassay (CPT 87320), and nucleic acid hybridization (the only nucleic acid hybridization test FDA approved for chlamydia testing the digene HC2 CT-ID DNA Test is an in vitro nucleic acid signal amplified, hybridization microplate assay and is to be reported using amplified probe technique CPT codes [CPT 87491]).
 
“C. trachomatis urogenital infection in women can be diagnosed by testing urine or by collecting swab specimens from the endocervix or vagina. Diagnosis of C. trachomatis urethral infection in men can be made by testing a urethral swab or urine specimen. Rectal C. trachomatis infections in persons that engage in receptive anal intercourse can be diagnosed by testing a rectal swab specimen.  Nucleic acid amplification tests (NAATs), cell culture, direct immunofluorescence, enzyme immunoassay (EIA), and nucleic acid hybridization tests are available for the detection of C. trachomatis on endocervical specimens and urethral swab specimens for men. NAATs are the most sensitive tests for these specimens and are U.S Food and Drug Administration (FDA)-cleared for use with urine. Some NAATs are cleared for use with vaginal swab specimens, which can be collected by a provider or self-collected by a patient. Self collected vaginal swab specimens perform at least as well as with other approved specimens using NAATs, and women find this screening strategy highly acceptable. Rectal and oropharyngeal C. trachomatis infection in persons engaging in receptive anal or oral intercourse can be diagnosed by testing at the anatomic site of exposure. Most tests, including NAAT and nucleic acid hybridization tests, are not FDA-cleared for use with rectal or oropharyngeal swab specimens, and chlamydia culture is not widely available for this purpose. However, NAATs have demonstrated improved sensitivity and specificity compared with culture for the detection of C. trachomatis at rectal sites and at oropharyngeal sites among men. Some laboratories have met Clinical Laboratory Improvement Amendments (CLIA) requirements and have validated NAAT testing on rectal swab specimens for C. trachomatis. Recent evidence suggests that the liquid-based cytology specimens collected for Papanicolaou (Pap) smears might be acceptable specimens for NAAT testing.”
 
The tests used should be appropriate to the patient population and clinical setting (Bright Futures, 2008).
 
2016 Update
In September 2014, The U.S. Preventive Services Task Force updated the recommendation for chlamydia screening. This recommendation essentially combined the two previous statements which separated populations into pregnant and non-pregnant. The current recommendation states: “The USPSTF recommends screening for chlamydia in sexually active women age 24 years and younger and in older women who are at increased risk for infection” (USPSTF, 2014).  

CPT/HCPCS:
87270Infectious agent antigen detection by immunofluorescent technique; Chlamydia trachomatis
87320Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; Chlamydia trachomatis
87490Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, direct probe technique
87491Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique
87800Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s) technique
87801Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified probe(s) technique
87810Infectious agent antigen detection by immunoassay with direct optical observation; Chlamydia trachomatis

References: CDC Sexually Transmitted Diseases Treatment Guidelines. MMWR, 2010; 59(RR-12):44-49

Coding for digene HC2 CT-ID DNA Test. http://www.qiagen.com/products/digenect-idhc2test.aspx#Tabs=t1 (accessed 2011-10-24)

Hagan JF, Shaw JS, Duncan P, eds.(2008) Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents, Pocket Guide. Third Edition. Elk Grove, Village, IL: American Academy of Pediatrics.

PPACA & HECRA: Public Laws 111-148 & 111-152. The Patient Protection and Affordable Care Act

Screening for Chlamydial Infection, Topic Page. June 2007. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspschlm.htm


Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
CPT Codes Copyright © 2019 American Medical Association.