Coverage Policy Manual
Policy #: 2011024
Category: PPACA Preventive
Initiated: September 2010
Last Review: August 2018
  PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: TOBACCO USE, SCREENING, COUNSELING AND INTERVENTIONS

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.  
 
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.
 

Policy/
Coverage:
EFFECTIVE AUGUST 2015
Screening for tobacco use including counseling and tobacco cessation interventions is covered for adult members of “non-grandfathered” plans, without cost-sharing (i.e., deductible, co-insurance, or co-pay). Screening for tobacco use including augmented, pregnancy-tailored counseling and interventions is covered for pregnant members (who smoke) of “non-grandfathered” plans, without cost-sharing (i.e., deductible, co-insurance, or co-pay).
 
Screening for tobacco use including counseling and tobacco cessation interventions is covered for school-aged children and adolescent members (greater than 5 years of age) of “non-grandfathered” plans, without cost-sharing (i.e., deductible, co-insurance, or co-pay). (Bright Futures Recommendation)
 
The appropriate ICD-9 codes to report these services are 305.1, V15.82, V15.89, 649.01- 649.04, V22.0- V22.2 and V23.0 – V23.9 or V65.49.
 
The appropriate ICD-10 codes to report these services are F17.200-F173.201, F17.210-F17.211, F17.220- F17.221, F17.290, F17.291, Z87.891, Z77.22, Z71.89, Z33.1, Z34.00-Z34.93, O09- O09.40, O09.519, O09.529-O09.93, O99.331-O99.335, Z71.89.
 
The CPT Code that may be used to report the counseling is 99406 or G0436. CPT code 99407 or HCPCS code G0437 would be used for tobacco cessation interventions. 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 AUGUST 2013 – July 2015
Screening for tobacco use including counseling and tobacco cessation interventions is covered for adult members of “non-grandfathered” plans, without cost-sharing (i.e., deductible, co-insurance, or co-pay).
  
Screening for tobacco use including augmented, pregnancy-tailored counseling and interventions is covered for pregnant members (who smoke) of “non-grandfathered” plans, without cost-sharing (i.e., deductible, co-insurance, or co-pay).
 
Screening for tobacco use including counseling and tobacco cessation interventions is covered for adolescent members (aged 11-21 years) of “non-grandfathered” plans, without cost-sharing (i.e., deductible, co-insurance, or co-pay). (Bright Futures Recommendation) (Effective Aug. 01, 2012)
 
The appropriate ICD-9 codes to report these services are  305.1, V15.82, V15.89, 649.0, V22.0- V22.2 and V23.0 – V23.9 or V65.49.
 
The CPT Code that may be used to report the counseling is 99406 or G0436. CPT code 99407 or HCPCS code G0437 would be used for tobacco cessation interventions. 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 August 2013
Screening for tobacco use including counseling and tobacco cessation interventions is covered for adult members of “non-grandfathered” plans, without cost-sharing (i.e., deductible, co-insurance, or co-pay).
 
Three counseling sessions will be allowed per member per year for non-pregnant adults.
 
Screening for tobacco use including augmented, pregnancy-tailored counseling and interventions is covered for pregnant members (who smoke) of “non-grandfathered” plans, without cost-sharing (i.e., deductible, co-insurance, or co-pay).
 
Four counseling sessions will be allowed per member per year for pregnant women.
 
Screening for tobacco use including counseling and tobacco cessation interventions is covered for adolescent members (aged 11-21 years) of “non-grandfathered” plans, without cost-sharing (i.e., deductible, co-insurance, or co-pay). (Bright Futures Recommendation) (Effective Aug. 01, 2012)
 
The appropriate ICD-9 codes to report these services are  305.1, V15.82, V15.89, 649.0, V22.0- V22.2 and V23.0 – V23.9 or V65.49.
 
The CPT Code that may be used to report the counseling is 99406 or G0436. CPT code 99407 or HCPCS code G0437 would be used for tobacco cessation interventions. 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 that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products (Grade A Recommendation).
 
The USPSTF recommends that clinicians ask all pregnant women about tobacco use and provide augmented, pregnancy-tailored counseling for those who smoke (Grade A Recommendation).
 
The USPSTF recommendations include the following information:
 
    • This recommendation applies to adults 18 years or older and all pregnant women regardless of age. The USPSTF plans to issue a separate recommendation statement about counseling to prevent tobacco use in nonpregnant adolescents and children.
    • Tobacco use, cigarette smoking in particular, is the leading preventable cause of death in the United States. Tobacco use results in more than 400,000 deaths annually from cardiovascular disease, respiratory disease, and cancer. Smoking during pregnancy results in the deaths of about 1000 infants annually and is associated with an increased risk for premature birth and intrauterine growth retardation. Environmental tobacco smoke contributes to death in an estimated 38,000 people annually.
    • The "5-A" behavioral counseling framework provides a useful strategy for engaging patients in smoking cessation discussions: 1) Ask about tobacco use; 2) Advise to quit through clear personalized messages; 3) Assess willingness to quit; 4) Assist to quit; and 5) Arrange follow-up and support.
    • In nonpregnant adults, the USPSTF found convincing evidence that smoking cessation interventions, including brief behavioral counseling sessions (<10 minutes) and pharmacotherapy delivered in primary care settings, are effective in increasing the proportion of smokers who successfully quit and remain abstinent for 1 year. Although less effective than longer interventions, even minimal interventions (<3 minutes) have been found to increase quit rates.
    • The USPSTF found convincing evidence that smoking cessation decreases the risk for heart disease, stroke, and lung disease.
    • In pregnant women, the USPSTF found convincing evidence that smoking cessation counseling sessions, augmented with messages and self-help materials tailored for pregnant smokers, increases abstinence rates during pregnancy compared with brief, generic counseling interventions alone. Tobacco cessation at any point during pregnancy yields substantial health benefits for the expectant mother and baby. The USPSTF found inadequate evidence to evaluate the safety or efficacy of pharmacotherapy during pregnancy.
    • Finding no published studies that describe harms of counseling to prevent tobacco use in adults or pregnant women, the USPSTF judged the magnitude of these harms to be no greater than small. Harms of pharmacotherapy are dependent on the specific medication used. In nonpregnant adults, the USPSTF judged these harms to be small.
    • The USPSTF concludes that there is high certainty that the net benefit of tobacco cessation interventions in adults is substantial.
    • The USPSTF also concludes that there is high certainty that the net benefit of augmented, pregnancy-tailored counseling in pregnant women is substantial.
    • This recommendation applies to adults 18 years or older and all pregnant women regardless of age. The USPSTF plans to issue a separate recommendation statement about counseling to prevent tobacco use in nonpregnant adolescents and children.
    • Various primary care clinicians may deliver effective interventions. There is a dose-response relationship between quit rates and the intensity of counseling (that is, more or longer sessions improve quit rates). Quit rates seem to plateau after 90 minutes of total counseling contact time.1 Helpful components of counseling include problem-solving guidance for smokers (to help them develop a plan to quit and overcome common barriers to quitting) and the provision of social support as part of treatment. Complementary practices that improve cessation rates include motivational interviewing, assessing readiness to change, offering more intensive counseling or referrals, and using telephone "quit lines."
    •  Combination therapy with counseling and medications is more effective at increasing cessation rates than either component alone. Pharmacotherapy approved by the U.S. Food and Drug Administration and identified as effective for treating tobacco dependence in nonpregnant adults includes several forms of nicotine replacement therapy (gum, lozenge, transdermal patch, inhaler, and nasal spray), sustained-release bupropion, and varenicline.
 

CPT/HCPCS:
99406Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes
99407Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes

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

Screening for Osteoporosis.(2011) U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsoste.htm. Last accessed May 2011.


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.
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