Coverage Policy Manual
Policy #: 2011035
Category: PPACA Preventive
Initiated: September 2010
Last Review: June 2022
  PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: GONORRHEA PROPHYLAXIS, NEWBORN OPHTHALMIC

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:
Prophylactic ocular topical medication for all newborns against gonococcal ophthalmia neonatorum within the first 28 days of life is covered without cost sharing (i.e., deductible, co-pay or co-insurance).  
 
The appropriate ICD-10 codes to report this service are Z00.110 or Z00.111.
 
This service is usually provided as part of newborn care when an infant is delivered in a hospital setting or birthing center.  For infants delivered in a setting outside of the hospital or birthing center and being seen for initial care CPT 99461 or 99381 should be used.
 
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:
There is good evidence that blindness due to gonococcal ophthalmia neonatorum has become rare in the United States since the implementation of universal preventive medication of infants (A recommendation)          
 
To prevent gonococcal ophthalmia neonatorum, a prophylactic agent should be instilled into the eyes of all newborn infants; this procedure is required by law in most states. Prophylactic regimens include a single application of silver nitrate (1%) aqueous solution, erythromycin (0.5%) ophthalmic ointment, or tetracycline ophthalmic ointment (1%), all of which are effective.
 
The USPSTF reviewed this guideline in 2011 and reaffirmed the recommendation statement.  

CPT/HCPCS:
99381Initial 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; infant (age younger than 1 year)
99461Initial care, per day, for evaluation and management of normal newborn infant seen in other than hospital or birthing center

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

Screening for gonorrhea, May 2005: U.S. Preventive Services Task Force; http://www.uspreventiveservicestaskforce.org/uspstf05/gonorrhea/gonrs.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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