Coverage Policy Manual
Policy #: 2012045
Category: PPACA Preventive
Initiated: August 2012
Last Review: October 2018
  PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: AUTISM SCREENING

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.
 
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).
 
The following policy is based on the Bright Futures recommendation for this preventive service.
 

Policy/
Coverage:
Autism specific screening is covered at the 18 month and 24 month well-child visits for members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance or co-pay).
 
The appropriate ICD-9 code to report these services are V20.2, V79.3 or V79.8. The appropriate ICD-10 codes to report this service are Z00.121, Z00.129 Z13.40, Z13.41, Z13.42, or Z13.49.
 
Codes that may be used to report this service include CPT 96110 and G0451.  
 
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 Third Edition of Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents gives the following information regarding screening for autism spectrum disorder (ASD). (Hagan, 2008).
 
It is important to consider autism spectrum disorders (ASDs) for 15-month-old children in routine developmental surveillance; in addition, specific screening tools are available and appropriate for the 18 and 24 Month Visits.
 
ASDs have become a major concern for all health care professionals. Common behavioral features of ASD include hand flapping, rocking, or twirling; hypersensitivity to a wide range of sensory experiences such as sound and touch; and extreme difficulties in adjusting to transitions and change. The prognosis can be greatly improved with early and intensive treatment. Therefore, early identification is critical. Health care professionals should consider the possibility of ASD as early as the child’s first year of life. Infants with ASD can show little interest in being held and may not be comforted by physical closeness with their parents. They have significant limitations in social smiling, eye contact, vocalization, and social play.
 
During the first half of the child’s second year, more specific deficits are often seen.
 
Red flags include:
• The child fails to orient to his name.
• The child shows impairment in joint attention skills (i.e., the child’s capacity to follow a caregiver’s gaze or follow the caregiver’s pointing, or the child’s own lack of showing and pointing).
• The child does not seem to notice when parents and siblings enter or leave the room.
• The child makes little or no eye contact and seems to be in his own world.
• Parents complain that the child has a “hearing problem” (i.e., he does not respond to speech directed at him).
• The child’s speech fails to develop as expected.
 
Because these signs of ASD are often difficult to elicit in the context of the pediatric well visit, health care professionals must listen carefully to the observations of parents and they must have a high index of suspicion regarding ASD. The 15 and 18 Month Visits are important times to consider ASD within routine developmental surveillance. For children who exhibit any of the red flags listed earlier, the health care professional can use one of the ASD screening tests developed for primary care providers.
 
The Bright Futures Tool and Resource Kit for clinicians includes instructions for two autism-specific screening tools; the Checklist for Autism in Toddlers (CHAT) and the Modified Checklist for Autism in Toddlers (M-CHAT).
 
The CHAT is a screening instrument composed of a short questionnaire that identifies children aged 18 months who are at risk for social-communication disorders. If a child fails the CHAT, repeat screening should be conducted approximately one month later. Any child failing the test on two occasions should be referred to a specialist because the CHAT is not a diagnostic tool.
 
The M-CHAT is validated for screening toddlers between 16 and 30 months of age, to assess the risk for ASD. The primary goal of the M-CHAT is to identify as many cases of ASD as possible.  Therefore, there is a high false positive rate. Not all children who score at a high risk for ASD will be diagnosed with ASD. Children who fail more than 3 items total or 2 critical items should be referred to a specialist for diagnostic evaluation.
 

CPT/HCPCS:
96110Developmental screening (eg, developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument
G0451Development testing, with interpretation and report, per standardized instrument form

References: Hagan JF, Shwa JS, Duncan PM, eds.(2008) Bright Futures: Guidelines for health supervision of infants, children and adolescents, 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics.

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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