Coverage Policy Manual
Policy #: 2011020
Category: PPACA Preventive
Initiated: September 2010
Last Review: June 2022
  PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: BACTERIURIA SCREENING IN PREGNANT 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 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:
Screening for asymptomatic bacteriuria with urine culture for pregnant persons is covered for members of “non-grandfathered” plans without cost-sharing (i.e., deductible, co-insurance, or co-pay).
 
The appropriate ICD-10 codes to report these services are Z34.00-Z34.93 and O09.00 -O09.93.
 
The codes used to report this procedure are 87081, 87084, 87086, or 87088.  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-10 and CPT or HCPCS codes are also required.  

Rationale:
The U.S. Preventive Services Task Force (USPSTF) recommends screening for  asymptomatic bacteriuria in pregnant women between 12-16 weeks gestation or the first prenatal visit, if later (Grade A recommendation).
 
The USPSTF recommendations include the following information:.
In pregnant women, asymptomatic bacteriuria has been associated with an increased incidence of pyelonephritis and low birthweight (birthweight <2500 g).
 
Asymptomatic bacteriuria can be reliably detected through urine culture. The presence of at least 105 colony-forming units per mL of urine, of a single uropathogen, and in a midstream clean-catch specimen is considered a positive test result.
 
In pregnant women, convincing evidence indicates that detection of and treatment for asymptomatic bacteriuria with antibiotics significantly reduces the incidence of symptomatic maternal urinary tract infections and low birthweight.
 
The USPSTF concludes that in pregnant women, there is high certainty that the net benefit of screening for asymptomatic bacteriuria is substantial.
 
In 2004,the USPSTF reviewed the evidence on screening for asymptomatic bacteriuria in adults and recommended screening pregnant women. In 2008, the USPSTF performed a brief literature review and determined that the net benefit of screening pregnant women and the net harm of screening men and nonpregnant women continue to be well established.  The update included a search for new and substantial evidence on the benefits and harms of screening. The USPSTF found no new substantial evidence that could change its recommendation and, therefore, reaffirms its recommendation to screen pregnant women, but not men or nonpregnant women, for asymptomatic bacteriuria. The previous recommendation statement and evidence report, as well as the 2008 summary of the updated literature search can be found at http://www.uspreventiveservicestaskforce.org.
 
The U.S. Preventive Services Task Force (USPSTF) released its final recommendation statement on screening for asymptomatic bacteriuria in adults on September 24, 2019 .The USPSTF recommends screening for asymptomatic bacteriuria using urine culture in pregnant persons Grade B recommendation).

CPT/HCPCS:
87081Culture, presumptive, pathogenic organisms, screening only;
87084Culture, presumptive, pathogenic organisms, screening only; with colony estimation from density chart
87086Culture, bacterial; quantitative colony count, urine
87088Culture, bacterial; with isolation and presumptive identification of each isolate, urine

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

Screening for Asymptomatic Bacteriuria in Adults, Topic Page. July 2008. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsbact.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.
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