Coverage Policy Manual
Policy #: 2011037
Category: PPACA Preventive
Initiated: September 2010
Last Review: December 2023
  PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: SYPHILIS 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.  
 
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 Syphilis is covered for members of “non-grandfathered” plans on an annual basis, without cost-sharing (i.e., deductible, co-insurance, or co-pay) for:
 
    • Persons at risk for Syphilis infection
    • All pregnant women
 
The appropriate ICD-10 codes to report these services are Z00.00-Z00.01, Z11.3, Z72.51-Z72.53, Z33.1, Z34.00-Z34.93, and O09-O09.40; O09.519, O09.529-O09.93.
 
Codes that may be used to report the screening for syphilis are CPT 86780, 86592 or 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.
 
 
Rationale:
The U.S. Preventive Services Task Force (USPSTF) strongly recommends that clinicians screen persons at increased risk for syphilis infection (Grade A Recommendation).
 
The USPSTF strongly recommends that clinicians screen all pregnant women for syphilis infection (Grade A Recommendation).
 
The USPSTF recommendations include the following information:
 
    • Populations at increased risk for syphilis infection (as determined by incident rates) include men who have sex with men and engage in high-risk sexual behavior, commercial sex workers, persons who exchange sex for drugs, and those in adult correctional facilities. There is no evidence to support an optimal screening frequency in this population. Clinicians should consider the characteristics of the communities they serve in determining appropriate screening strategies. Prevalence of syphilis infection varies widely among communities and patient populations. For example, the prevalence of syphilis infection differs by region (the prevalence of infection is higher in the southern U.S. and in some metropolitan areas than it is in the U.S. as a whole) and by ethnicity (the prevalence of syphilis infection is higher in Hispanic and African American populations than it is in the white population).
 
    • Persons diagnosed with other sexually transmitted diseases (STDs) (i.e., chlamydia, gonorrhea, genital herpes simplex, human papilloma virus, and HIV) may be more likely than others to engage in high-risk behavior, placing them at increased risk for syphilis; however, there is no evidence that supports the routine screening of individuals diagnosed with other STDs for syphilis infection. Clinicians should use clinical judgment to individualize screening for syphilis infection based on local prevalence and other risk factors.
 
    • Nontreponemal tests commonly used for initial screening are the Venereal Disease Research Laboratory (VDRL) or Rapid Plasma Reagin (RPR), followed by a confirmatory fluorescent treponemal antibody absorbed (FTA-ABS) or T. pallidum particle agglutination (TP-PA). The optimal screening interval in average- and high-risk persons has not been determined.
 
    • All pregnant women should be tested at their first prenatal visit. For women in high-risk groups, repeat serologic testing may be necessary in the third trimester and at delivery. Followup serologic tests should be obtained to document decline initially after treatment. These followup tests should be performed using the same nontreponemal test initially used to document infections (e.g., VDRL or RPR) to ensure comparability.
 
CPT/HCPCS:
80055Obstetric panel This panel must include the following: Blood count, complete (CBC), automated and automated differential WBC count (85025 or 85027 and 85004) OR Blood count, complete (CBC), automated (85027) and appropriate manual differential WBC count (85007 or 85009) Hepatitis B surface antigen (HBsAg) (87340) Antibody, rubella (86762) Syphilis test, non treponemal antibody; qualitative (eg, VDRL, RPR, ART) (86592) Antibody screen, RBC, each serum technique (86850) Blood typing, ABO (86900) AND Blood typing, Rh (D) (86901)
80081Obstetric panel (includes HIV testing) This panel must include the following: Blood count, complete (CBC), and automated differential WBC count (85025 or 85027 and 85004) OR Blood count, complete (CBC), automated (85027) and appropriate manual differential WBC count (85007 or 85009) Hepatitis B surface antigen (HBsAg) (87340) HIV 1 antigen(s), with HIV 1 and HIV 2 antibodies, single result (87389) Antibody, rubella (86762) Syphilis test, non treponemal antibody; qualitative (eg, VDRL, RPR, ART) (86592) Antibody screen, RBC, each serum technique (86850) Blood typing, ABO (86900) AND Blood typing, Rh (D) (86901)
86592Syphilis test, non treponemal antibody; qualitative (eg, VDRL, RPR, ART)
86780Antibody; Treponema pallidum
References: PPACA & HECRA: Public Laws 111-148 & 111-152. The Patient Protection and Affordable Care Act.

Screening for lipid disorders in adults.(2011) U.S. Preventive Services Task Force. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspssyph.htm. Last accessed May 2011.
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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