Coverage Policy Manual
Policy #: 2011038
Category: PPACA Preventive
Initiated: September 2010
Last Review: April 2018
  PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: GONORRHEA 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 was established by the Health and Human Services (HHS) Health Resources and Services Administration’s Maternal and Child Health Bureau with the mission to “promote and improve the health, education, and wellbeing of infants, children, adolescents, families and communities” (AAP, 2008).
 
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).
 

Policy/
Coverage:
EFFECTIVE AUGUST 2015
Screening for gonorrhea infection is covered without cost sharing (i.e., deductible, co-insurance or co-pay) for:
 
    • All sexually active women, including those who are pregnant, if they are at increased risk for infection (See Clinical Considerations for further discussion of risk factors).
    • Sexually active male or female adolescents between 11-21 years of age.
 
The appropriate ICD-9 codes to report these services are V22.0-V22.2, V23.0-V23.9, V70.0, V74.5 or V69.2.
 
The appropriate ICD-10 codes to report these services are O09-O09.40, O09.519, O09.529-O09.93, Z00.00-Z00.01, Z11.3, Z34.00-Z34.93, Z72.51-Z72.53.
 
Codes that may be used to report these services include 87590, 87591, 87850, 87800, or 87801.
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.
 
The optimal frequency of rescreening is not known but women should be screened at the first prenatal visit of each pregnancy. Rescreening in women who are not pregnant should be considered annually if the activities resulting in increased risk for infection continue.
 
EFFECTIVE AUGUST 2013 to July 2015
Screening for gonorrhea infection is covered without cost sharing (i.e., deductible, co-insurance or co-pay) for:
 
    • All sexually active women, including those who are pregnant, if they are at increased risk for infection (See Clinical Considerations for further discussion of risk factors).
    • Sexually active male or female adolescents between 11-21 years of age.
 
The appropriate ICD-9 code to report these services is V74.5 or V69.2.
 
Codes that may be used to report these services include 87590, 87591, 87850, 87800, or 87801.  
 
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.
 
The optimal frequency of rescreening is not known but women should be screened at the first prenatal visit of each pregnancy.  Rescreening in women who are not pregnant should be considered annually if the activities resulting in increased risk for infection continue.  
 
EFFECTIVE PRIOR TO AUGUST 2013
Screening of  all sexually active women, including those who are pregnant, for gonorrhea infection if they are at increased risk for infection (that is, if they are young or have other individual or population risk factors; see Clinical Considerations for further discussion of risk factors) is covered without cost sharing (i.e., deductible, co-insurance or co-pay).  
 
The appropriate ICD-9 code to report these services is V74.5 or V69.2.
 
Codes that may be used to report these services include 87590, 87591, 87850, 87800, or 87801.  
 
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.
 
The optimal frequency of rescreening is not known but women should be screened at the first prenatal visit of each pregnancy.  Rescreening in women who are not pregnant should be considered annually if the activities resulting in increased risk for infection continue.  

Rationale:
Women with asymptomatic gonorrhea infection have high morbidity due to pelvic inflammatory disease, ectopic pregnancy, and chronic pelvic pain. Pregnant women with gonorrhea infection are at risk for preterm rupture of membranes, preterm labor, and chorioamnionitis. There is fair evidence that screening tests can accurately detect gonorrhea infection and good evidence that antibiotics can cure gonorrhea infection. There is fair evidence that screening pregnant women at high risk for gonorrhea, including women at high risk because of younger age, may prevent other complications associated with gonococcal infection during pregnancy, such as preterm delivery and chorioamnionitis. Potential harms of screening and treatment for gonorrhea include false-positive test results, anxiety, and unnecessary antibiotic use. There is insufficient evidence (due to a lack of studies) to quantify the magnitude of these potential harms. The USPSTF judges the magnitude of the potential harms to be small. The USPSTF concludes that the benefits of screening women at increased risk for gonorrhea infection outweigh the potential harms.
 
The U.S. Preventive Services Task Force (USPSTF) found insufficient evidence to recommend for or against routine screening for gonorrhea infection in men at increased risk for infection (see Clinical Considerations for discussion of risk factors). (I recommendation)
Rationale: The morbidity from undiagnosed and untreated genital gonorrhea infection is lower in men than in women. Clinical symptoms are more likely to lead to diagnosis and treatment in men; thus, the prevalence of asymptomatic infection in men is lower. There is fair evidence that non-invasive screening tests can accurately detect gonorrhea infection and good evidence that antibiotics cure gonorrhea infection. Potential harms of screening and treatment for gonorrhea include false-positive test results, anxiety, and unnecessary antibiotic use. There is insufficient evidence (due to a lack of studies) to quantify the magnitude of these potential harms. The USPSTF judges the magnitude of the potential harms of screening men for gonorrhea to be small. Given the low prevalence of asymptomatic infection in men, the USPSTF could not determine the balance of benefits and harms of screening for gonorrhea infection in men at increased risk for infection.
 
The USPSTF recommends against routine screening for gonorrhea infection in men and women who are at low risk for infection (see Clinical Considerations for discussion of risk factors). (D recommendation)
Rationale: There is a low prevalence of gonorrhea infection in the general population and consequently a low yield from screening. Thus, the USPSTF concludes that potential harms of screening (i.e., false-positive test results and labeling) in low-prevalence populations outweigh the benefits.
 
The USPSTF found insufficient evidence to recommend for or against routine screening for gonorrhea infection in pregnant women who are not at increased risk for infection (see Clinical Considerations for discussion of risk factors). (I recommendation)
Rationale: The prevalence of gonorrhea infection in pregnant women who are not at increased risk for infection is low. The USPSTF could not determine the balance between benefits and harms of screening for gonorrhea in pregnant women who are not at increased risk for infection.
 
CLINICAL CONSIDERATIONS
  • Women and men under the age of 25—including sexually active adolescents—are at highest risk for genital gonorrhea infection. Risk factors for gonorrhea include a history of previous gonorrhea infection, other sexually transmitted infections, new or multiple sexual partners, inconsistent condom use, sex work, and drug use. Risk factors for pregnant women are the same as for non-pregnant women. Prevalence of gonorrhea infection varies widely among communities and patient populations. African Americans and men who have sex with men have a higher prevalence of infection than the general population in many communities and settings.
  • Individual risk depends on the local epidemiology of disease. Local public health authorities provide guidance to clinicians to help identify populations who are at increased risk in their communities. In communities with a high prevalence of gonorrhea, broader screening of sexually active young people may be warranted, especially in settings serving individuals who are at increased risk. Additionally, clinicians may want to consider other population-based risk factors, including residence in urban communities and communities with high rates of poverty, when making screening decisions. Low community prevalence of gonorrhea infection may justify more targeted screening.
  • Screening is recommended at the first prenatal visit for pregnant women who are in a high risk group for gonorrhea infection. For pregnant patients who are at continued risk, and for those who acquire a new risk factor, a second screening should be conducted during the third trimester. The optimal interval for screening in the non-pregnant population is not known.
  • Vaginal culture remains an accurate screening test when transport conditions are suitable. Newer screening tests, including nucleic acid amplification tests and nucleic acid hybridization tests, have demonstrated improved sensitivity and comparable specificity when compared with cervical culture. Some newer tests can be used with urine and vaginal swabs, which enables screening when a pelvic examination is not performed.
  • Appropriate treatment of gonorrhea infection and administration of prophylactic medication to newborns have been outlined by the Centers for Disease Control and Prevention (CDC) (http://www.cdc.gov/std/treatment/). Genital infection in men and women may be treated with a third generation cephalosporin or fluoroquinolone, and pregnant women may be treated with third generation cephalosporins. Because of emerging fluoroquinolone resistance, the CDC issued new treatment guidelines in 2004 recommending that men who have sex with men and those who acquired an infection in California, Hawaii, or Asia not be treated with fluoroquinolone antibiotics. If clinicians have not concurrently screened for chlamydial infection, the CDC recommends presumptive treatment for chlamydia at the time of treatment for gonorrhea. In order to prevent recurrent transmission, partners of infected individuals should be tested and treated if infected, or treated presumptively.
  • Gonorrhea is a nationally reportable condition. More complete reporting of gonorrhea cases to public health authorities will permit more accurate estimations of gonorrhea prevalence. Improved information will allow clinicians to screen for gonorrhea in ways that improve the balance between benefits and harms for their patients.
  • Research priorities for gonorrhea screening include greater understanding of the benefits of screening men at increased risk, especially men who have sex with men, and the role of reporting on gonorrhea rates and testing priorities.
  • See other USPSTF recommendations on screening for sexually transmitted infections (chlamydial infection, hepatitis B and C virus infection, HIV, genital herpes simplex, and syphilis) at http://www.uspreventiveservicestaskforce.org/recommendations.htm#infectious.
 

CPT/HCPCS:
87590Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, direct probe technique
87591Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, 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
87850Infectious agent antigen detection by immunoassay with direct optical observation; Neisseria gonorrhoeae

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

Screening for Gonorrhea, May 2005: U.S. Preventive Services Task Force http://www. uspreventiveservicestaskforce.org/uspstf05/gonorrhea/gonrs.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.