Coverage Policy Manual
Policy #: 2012031
Category: PPACA Preventive
Initiated: August 2012
Last Review: May 2018
  PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: WELL-WOMAN VISITS FOR ADULT WOMEN

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 September 23, 2010. Preventive services that have strong scientific evidence of their health benefits must be covered and plans can no longer charge a patient a copayment, coinsurance or deductible for these services when they are delivered by a network provider.   A component of the law was a requirement that all “non-grandfathered” health insurance plans are required to provide coverage without cost sharing consistent with the Health Resources and Services Administration ‘s (HRSA’s) Women's Preventive Services: Required Health Plan Coverage Guidelines.
 
The HRSA-supported health plan coverage guidelines were developed by the Department of Health and Human Services (HHS) commissioned Institute of Medicine (IOM). HHS commissioned an IOM study to review what preventive services are necessary for women’s health and well-being and should be considered in the development of comprehensive guidelines for preventive services for women.  HRSA supports the IOM’s recommendations on preventive services that address health needs specific to women and fill gaps in existing guidelines.
 
Non-grandfathered plans and issuers are required to provide coverage without cost sharing consistent with these guidelines starting August 1, 2012.  
 
Plans are not required to provide coverage for the preventive services if they are delivered by out-of-network providers.
 

Policy/
Coverage:
Effective May 2018
Annual preventive care visits (including preconception and prenatal care) are covered for members of “non-grandfathered” plans for women 18 years of age or older. One visit per year is covered without cost sharing (i.e., deductible, co-insurance or co-pay).
 
*Note: Preconception and prenatal care visits are covered for covered dependent pregnant daughters of any age.
 
The appropriate ICD-9 codes to report these services are V70.0, V72.31, V22.0, V22.1, V22.2, V23.0, V23.1, V23.2, V23.3, V23.41, V23.42, V23.49, V23.5, V23.7, V23.81, V23.82, V23.83, V23.84, V23.85, V23.86, V23.87, V23.89, V23.9.
 
The appropriate ICD-10 codes to report these services are O09-O09.40, O09.519, O09.529-O09.93, Z00.00, Z00.01,  Z01.419 and Z3400-Z34.93.
 
Codes that may be used to report this service include CPT codes 99383, 99384, 99385, 99386, 99387, 99393, 99394 99395, 99396, 99397, 59425, 59426 or HCPCS codes G0101, G0438, G0439, S0610 or S0612.
 
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 May 2018
Annual preventive care visits (including preconception and prenatal care) are covered for members of “non-grandfathered” plans for women 18 years of age or older. One visit per year is covered without cost sharing (i.e., deductible, co-insurance or co-pay).
 
*Note: Preconception and prenatal care visits are covered for covered dependent pregnant daughters of any age.
 
The appropriate ICD-9 codes to report these services are V70.0, V22.0, V22.1, V22.2, V23.0, V23.1, V23.2, V23.3, V23.41, V23.42, V23.49, V23.5, V23.7, V23.81, V23.82, V23.83, V23.84, V23.85, V23.86, V23.87, V23.89, V23.9.
 
The appropriate ICD-10 codes to report these services are O09-O09.40, O09.519, O09.529-O09.93, Z00.00, Z00.01,  and Z3400-Z34.93.
 
Codes that may be used to report this service include CPT codes 99383, 99384, 99385, 99386, 99387, 99393, 99394 99395, 99396, 99397, 59425, 59426 or HCPCS codes G0101, G0438, G0439, S0610 or S0612.
 
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.
 
June 2015 – November 2015
 
Annual preventive care visits are covered for members of “non-grandfathered” plans for women 18 years of age or older. One visit per year is covered without cost sharing (i.e., deductible, co-insurance or co-pay).
 
The appropriate ICD-9 codes to report these services are V70.0, V22.0, V22.1, V22.2, V23.0, V23.1, V23.2, V23.3, V23.41, V23.42, V23.49, V23.5, V23.7, V23.81, V23.82, V23.83, V23.84, V23.85, V23.86, V23.87, V23.89, V23.9.
 
Codes that may be used to report this service include CPT codes 99385, 99386, 99387, 99395, 99396, 99397, 59425, 59426 or HCPCS codes G0438 or G0439.
 
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 June 2015
Annual preventive care visits are covered for members of “non-grandfathered” plans between the ages of 21-64 years. One visit per year is covered without cost sharing (i.e., deductible, co-insurance or co-pay).
 
The appropriate ICD-9 code to report these services is V70.0.  
 
Codes that may be used to report this service include CPT codes 99385, 99386, 99387, 99395, 99396, 99397, 59425, 59426 or HCPCS codes G0438 or G0439.
 
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 HRSA-supported health plan coverage guidelines recommend well-woman preventive care visits at least annually for women 21-64 years of age to address the gaps in preventive services for women in the existing guidelines (IOM, 2011).
 
The Institute of Medicine suggests the following services:
    • Determine current levels of physical activity and eating behaviors in all adolescent and adult women and make referrals to appropriate services.
    • Obtain a history of pregnancy complications, including preeclampsia, gestational hypertension, and gestational diabetes mellitus, from all women who have had at least one pregnancy.
    • Screen for suicide ideation and postpartum depression in women who are pregnant or who have recently given birth.
    • Obtain a waist circumference as an essential component of screening for metabolic syndrome.
    • Provide evidence-based tests, procedures, and screening for non-pregnant women to optimize reproductive outcomes and prevent or optimize treatment for chronic conditions, as well as topics for counseling and guidance for preconception health.
    • Provide evidence-based tests, procedures, and screening for pregnant women to optimize birth outcomes and future chronic conditions, as well as topics for counseling and guidance for prenatal care.
    • Screen for Chlamydia and gonorrhea for women above age 25 years with risk factors outlined by the USPSTF or if local rates of infections are high. High-prevalence settings are defined by the Centers for Disease Control and Prevention as those known to have a one percent or greater prevalence of infection among the patient population being served.
 
 
 

CPT/HCPCS:
59425Antepartum care only; 4-6 visits
59426Antepartum care only; 7 or more visits
99383Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; late childhood (age 5 through 11 years)
99384Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; adolescent (age 12 through 17 years)
99385Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 18-39 years
99386Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 40-64 years
99387Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 65 years and older
99393Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; late childhood (age 5 through 11 years)
99394Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 years)
99395Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18-39 years
99396Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years
99397Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and older
G0101Cervical or vaginal cancer screening; pelvic and clinical breast examination
G0438Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit
G0439Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit
S0610Annual gynecological examination, new patient
S0612Annual gynecological examination, established patient

References: IOM (Institute of Medicine). Clinical Preventive Services for Women: Closing the Gaps. Washington, DC: The National Acadamies Press.


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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