Coverage Policy Manual
Policy #: 2012035
Category: PPACA Preventive
Initiated: August 2012
Last Review: October 2018
  PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: CONTRACEPTIVE USE AND COUNSELING

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:
Food and Drug Administration-approved contraceptive methods (not including abortifacient drugs), sterilization procedures and patient education and counseling, is covered for members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance or co-pay) for all women of child-bearing potential.
 
Over-the-counter (OTC) products (condoms, sponges, diaphragms, spermicides, etc.) are not covered.
 
There is a $0 copayment for all generic prescription contraceptives. If there is no generic in the class or subclass, then the brand contraceptive is at $0 copayment.
 
Emergency contraceptives for members who are less than 18 years old for Plan B and those who are less than 17 years old for Plan B One-Step is covered if a prescription is presented for coverage. NOTE: Those patients at or above the ages previously mentioned do not need a prescription to get access to emergency contraceptives as they are available OTC in these age groups and are not covered.
 
The appropriate ICD-9 codes to report these services are V25.01, V25.02, V25.03, V25.04, V25.09, V25.11, V25.12, V25.13, V25.2, V25.40, V25.41, V25.42, V25.43, V25.49, V25.5, V25.8 OR V25.9.  
 
The appropriate ICD-10 codes to report these services are: Z30.02, Z30.09, Z30.011, Z30.012, Z30.013, Z30.014, Z30.017, Z30.018, Z30.019, Z30.2, Z30.40, Z30.41, Z30.42, Z30.49, Z30.430, Z30.431, Z30.432, Z30.433, Z30.8, Z30.9.
 
Codes that may be used to report this service include CPT 11976, 11980,11981, 11982, 11983, 57170, 58300, 58301, 58340, 58600,  58605,  58611, 58615, 58670, 58671, 64435, 00851, 74740, 96372,  99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99384, 99385, 99386, 99394, 99395, 99396, OR HCPCS G0438, G0439, S4981,  S4989, S4993, A4261, A4266, J1050, J7296, J7297, J7298, J7300, J7301, J7303, J7304, J7306 or J7307, and Q9984.
 
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:
Contraception and contraceptive counseling is not currently addressed as a preventive service recommended by the USPSTF guidelines.
 
The HRSA-supported health plan coverage guidelines recommend provisions for all Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling for women of childbearing potential.  According to the committee, this recommendation is based on the following:
    • systematic reviews and peer-reviewed literature indicating that contraception and counseling reduce unintended pregnancy;
    • Current federal reimbursement policies provide coverage for contraception and contraceptive counseling, and most private insurers also cover contraception in their health plans;
    • Numerous health professional associations recommend family planning services as part of preventive care for women;  And
    •   A reduction in unintended pregnancies has been identified as a specific goal in Health People 2010 and Health People 2020.
 
2012 Update
ACOG (#539; Oct 2012) has issued a Committee Opinion on the use of implants and intrauterine devices for long-acting reversible contraception for adolescents:
 
“When choosing contraceptive methods, adolescents should be encouraged to consider Long Acting Reversible Contraception methods.  Intrauterine devices and the contraceptive implant are the best reversible methods for preventing unintended pregnancy, rapid repeat pregnancy, and abortion in young women.  Counseling about LARC methods should occur at all health care provider visits with sexually active adolescents, including preventive health, abortion, prenatal, and postpartum visits.  Complications of IUDs and the contraceptive implant are rare and differ little between adolescents and older women.  Health care providers should consider LARC methods for adolescents and help make these methods accessible to them.”
 

CPT/HCPCS:
00851Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; tubal ligation/transection
11976Removal, implantable contraceptive capsules
11980Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets beneath the skin)
11981Insertion, non-biodegradable drug delivery implant
11982Removal, non-biodegradable drug delivery implant
11983Removal with reinsertion, non-biodegradable drug delivery implant
57170Diaphragm or cervical cap fitting with instructions
58300Insertion of intrauterine device (IUD)
58301Removal of intrauterine device (IUD)
58340Catheterization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalpingography
58600Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral
58605Ligation or transection of fallopian tube(s), abdominal or vaginal approach, postpartum, unilateral or bilateral, during same hospitalization (separate procedure)
58611Ligation or transection of fallopian tube(s) when done at the time of cesarean delivery or intra-abdominal surgery (not a separate procedure) (List separately in addition to code for primary procedure)
58615Occlusion of fallopian tube(s) by device (eg, band, clip, Falope ring) vaginal or suprapubic approach
58670Laparoscopy, surgical; with fulguration of oviducts (with or without transection)
58671Laparoscopy, surgical; with occlusion of oviducts by device (eg, band, clip, or Falope ring)
64435Injection, anesthetic agent; paracervical (uterine) nerve
74740Hysterosalpingography, radiological supervision and interpretation
99201Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.
99202Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 20 minutes are spent face-to-face with the patient and/or family.
99203Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family.
99204Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family.
99205Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family.
99212Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.
99213Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family.
99214Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family.
99215Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent face-to-face with the patient and/or family.
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
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
A4261Cervical cap for contraceptive use
J1050Injection, medroxyprogesterone acetate, 1 mg
J7296Levonorgestrel-releasing intrauterine contraceptive system, (kyleena), 19.5 mg
J7297Levonorgestrel-releasing intrauterine contraceptive system (liletta), 52 mg
J7298Levonorgestrel-releasing intrauterine contraceptive system (mirena), 52 mg
J7300Intrauterine copper contraceptive
J7301Levonorgestrel-releasing intrauterine contraceptive system (skyla), 13.5 mg
J7303Contraceptive supply, hormone containing vaginal ring, each
J7304Contraceptive supply, hormone containing patch, each
J7306Levonorgestrel (contraceptive) implant system, including implants and supplies
J7307Etonogestrel (contraceptive) implant system, including implant and supplies
Q9984Levonorgestrel-releasing intrauterine contraceptive system (Kyleena), 19.5 mg
S4981Insertion of levonorgestrel-releasing intrauterine system
S4989Contraceptive intrauterine device (e.g., Progestacert IUD), including implants and supplies
S4993Contraceptive pills for birth control

References: AGOG Committee on Adolescent Health Care.(2012) Adolescents and Long-Acting Reversible Contraception: Implants and Intrauterine Devices. www.agog.org, #539, October 2012

IOM (Institute of Medicine).(2011) 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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