| Coverage Policy Manual | |
| Policy #: | 2011039 |
| Category: | PPACA Preventive |
| Initiated: | September 2010 |
| Last Review: | September 2023 |
|
|
|
|||||||||||
| PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: HEPATITIS B VIRUS INFECTION SCREENING IN PREGNANCY AND ASYMPTOMATIC ADOLESCENTS AND ADULTS | |
|
|
|
| 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: |
EFFECTIVE JANUARY 2019
Screening in Pregnant Females
Screening for hepatitis viral infection during pregnancy is covered for women of “non-grandfathered” plans at the time of their first prenatal visit.
The appropriate ICD-10 codes to report these services are O09-O09.40, O09.519, O09.529-O09.93, Z00.00, Z00.01, Z11.59, Z20.5, Z33.1, Z34.00-Z34.93, Z36.89, Z36.9, Z57.8, Z72.89, Z72.9 or Z73.9 .
Codes that may be used to report this service are 80055, 87340, 80081 and G0499. CPT 87340 is included in 80055 and is not separately billable whether done on the same or a different date of service during the pregnancy.
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.
Screening in Asymptomatic Adolescents and Adults
Screening (up to three times per year) is covered for hepatitis B virus (HBV) infection in persons 11 years of age or older at high risk for infection for members of “non-grandfathered” plans.
The appropriate ICD-10 codes to report these services are Z00.00-Z00.01, Z11.3, Z11.59, Z20.2, Z20.5, Z20.6, Z57.8, Z72.89, Z72.9, Z72.51, Z72.52, Z72.53, Z73.9.
The appropriate code used to report this service is CPT 87340, 80081 or HCPCS G0499.
EFFECTIVE PRIOR TO JANUARY 2019
Screening in Pregnant Females
Screening for hepatitis viral infection during pregnancy is covered for women of “non-grandfathered” plans at the time of their first prenatal visit.
The appropriate ICD-9 codes to report these services are V01.79, V15.85, V22.0-V22.2, V23.0-V23.9, V28.89, V28.9, V69.8, V69.9, V70.0, V73.89 or V73.99.
The appropriate ICD-10 codes to report these services are O09-O09.40, O09.519, O09.529-O09.93, Z00.00, Z00.01, Z11.59, Z20.5, Z34.00-Z34.93, Z36.89, Z36.9, Z57.8, Z72.89, Z72.9 or Z73.9 .
Codes that may be used to report this service are 80055, 87340, 80081 and G0499. CPT 87340 is included in 80055 and is not separately billable whether done on the same or a different date of service during the pregnancy.
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.
Screening in Asymptomatic Adolescents and Adults
Screening (up to three times per year) is covered for hepatitis B virus (HBV) infection in persons 11 years of age or older at high risk for infection for members of “non-grandfathered” plans.
The appropriate ICD-9 codes to report these services are V01.6. V01.79, V15.85, V69.2, V69.8, V69.9, V70.0, V73.89 or V73.99.
The appropriate ICD-10 codes to report these services are Z00.00-Z00.01, Z11.3, Z11.59, Z20.2, Z20.5, Z20.6, Z57.8, Z72.89, Z72.9, Z72.51, Z72.52, Z72.53, Z73.9.
The appropriate code used to report this service is CPT 87340, 80081 or HCPCS G0499.
EFFECTIVE PRIOR TO JANUARY 2016
Screening for hepatitis viral infection during pregnancy is covered for women of “non-grandfathered” plans at the time of their first prenatal visit.
The appropriate ICD-9 code to report these services is V28.9, V22.0-V22.2 or V23.0-V23.9.
Codes that may be used to report this service are 80055 and 87340. CPT 87340 is included in 80055 and is not separately billable whether done on the same or a different date of service during the pregnancy.
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 U.S. Preventive Services Task Force (USPSTF) recommends screening for hepatitis B virus (HBV) infection in pregnant women at their first prenatal visit. (A recommendation) This recommendation applies to all pregnant women.
An estimated 24 000 infants are born each year to women in the United States who are infected with HBV. Between 30% and 40% of all chronic HBV infections result from perinatal transmission. Chronic HBV infections increase long-term morbidity and mortality by predisposing infected persons to cirrhosis of the liver and liver cancer.
The principal screening test for detecting maternal HBV infection is the serologic identification of hepatitis B surface antigen (HBsAg). Immunoassays for detecting HBsAg have a reported sensitivity and specificity greater than 98%.
A test for HBsAg should be ordered at the first prenatal visit with other recommended screening tests. At the time of admission to a hospital, birth center, or other delivery setting, women with unknown HBsAg status or with new or continuing risk factors for HBV infection (such as injection drug use or evaluation or treatment for a sexually transmitted disease) should receive screening.
Screening in Asymptomatic Adolescents and Adults
The USPSTF recommends screening for hepatitis B virus (HBV) infection in persons at high risk for infection (Grade B recommendation).
The USPSTF recommendation (LeFevre ML, 2014) includes the following information:
Approximately 700,000 to 2.2 million persons in the United States have chronic HBV infectionIn the United States, persons considered at high risk for HBV infection include those from countries with a high prevalence of HBV infection, HIV-positive persons, injection drug users, household contacts of persons with HBV infection, and men who have sex with men.
The natural history of chronic HBV infection varies but can include the potential long-term sequelae of cirrhosis, hepatic decompensation, and hepatocellular carcinoma. An estimated 15% to 25% of persons with chronic HBV infection die of cirrhosis or hepatocellular carcinoma. Those with chronic infection also serve as a reservoir for person-to-person transmission of HBV infection. Screening for HBV infection could identify chronically infected persons who may benefit from treatment or other interventions, such as surveillance for hepatocellular carcinoma.
The prevalence of HBV infection is low in the general U.S. population, and most infected persons do not develop complications. Therefore, screening is not recommended in those who are not at increased risk. The USPSTF notes that high rates of HBV infection have been found in cities and other areas with high numbers of immigrants or migrant persons from Asia or the Pacific Islands or their adult children. Providers should consider the population they serve when making screening decisions.
The CDC recommends screening for HBsAg with tests approved by the U.S. Food and DrugAdministration, followed by a licensed, neutralizing confirmatory test for initially reactive results
Periodic screening may be useful in patients with ongoing risk for HBV transmission (for example, active injection drug users, men who have sex with men, and patients receiving hemodialysis) who do not receive vaccination. Clinical judgment should determine screening frequency, because the USPSTF found inadequate evidence to determine specific screening intervals.
|
|
|
|
| CPT/HCPCS: | |
|
|
|
| References: |
LeFevre ML.(2014) Screening for Hepatitis B Virus Infection in Nonpregnant Adolescents and Adults: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2014;161:58-66. doi:10.7326/M14-1018 PPACA & HECRA: Public Laws 111-148 & 111-152. The Patient Protection and Affordable Care Act Screening for Hepatitis B VirusInfection in Pregnancy, June 2009: U.S.Preventive Services Task Force http://www.uspreventiveservicestaskforce.org/uspstf09/hepb/hepbpgrs.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.
CPT Codes Copyright © 2024 American Medical Association. |
|