| Coverage Policy Manual | |
| Policy #: | 2011027 |
| Category: | PPACA Preventive |
| Initiated: | September 2010 |
| Last Review: | December 2023 |
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| PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: RH INCOMPATABILITY SCREENING | |
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| 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.
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Policy/ Coverage: |
Rh (D) blood typing and antibody testing for all pregnant women during their first visit for pregnancy-related care is covered for up to two per year for members of “non-grandfathered” plans, without cost-sharing (i.e., deductible, co-insurance, or co-pay).
Repeat Rh (D) antibody testing for all unsensitized Rh (D)-negative women is covered at 24-28 weeks gestation (unless the biological father is known to be Rh (D)-negative) for up to two per year for members of “non-grandfathered” plans, without cost-sharing (i.e., deductible, co-insurance, or co-pay).
The appropriate ICD-10 code to report these services are Z33.1, Z34.00-Z34.93, O09-O09.40, O09.519, O09.529-O09.93.
CPT Codes that may be used to report the screening for Rh incompatibility include 86901 and 80055. 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.
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| Rationale: |
The U.S. Preventive Services Task Force (USPSTF) strongly recommends Rh (D) blood typing and antibody testing for all pregnant women during their first visit for pregnancy-related care (Grade A Recommendation).
The USPSTF recommends repeated Rh (D) antibody testing for all unsensitized Rh (D)-negative women at 24-28 weeks' gestation, unless the biological father is known to be Rh (D)-negative (Grade B Recommendation).
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| CPT/HCPCS: | |
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| References: |
PPACA & HECRA: Public Laws 111-148 & 111-152. The Patient Protection and Affordable Care Act. Screening for Osteoporosis.(2011) U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsdrhi.htm. Last accessed May 2011. |
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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 © 2024 American Medical Association. |
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