| Coverage Policy Manual | |
| Policy #: | 2011043 |
| Category: | PPACA Preventive |
| Initiated: | September 2010 |
| Last Review: | April 2024 |
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| PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: DEPRESSION AND ANXIETY SCREENING, ADULTS | |
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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: |
For contracts subject to Arkansas Act 316, SCREENING FOR DEPRESSION OF BIRTH MOTHERS, [individual, blanket, or any group plan, policy, or contract for healthcare services issued, renewed, or extended in this state by a healthcare insurer, health maintenance organization, hospital medical service corporation, or self-insured governmental or church plan in this state (all fully-insured and state government such as ASE/PSE, ASP)] coverage shall be provided for depression screening for birth mothers at the time of birth or within the first six weeks of birth. For all contracts not subject to Ark law [e.g. federally chartered contracts such as ERISA groups, Federal Employee Health Benefit Program, and Medicare Advantage], these benefits will be provided as directed by PPACA.
Effective January 2025
The USPSTF recommends screening for depression in the general adult population, including pregnant and postpartum women. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.
Screening for anxiety in adults, including those who are pregnant or postpartum, is covered for members of “non-grandfathered” plans on an annual basis without cost sharing (i.e., deductible, co-pay, or co-insurance).
Codes that may be used to report these services include 96127, 96160, 96161, 99385-99387, 99395-99397, 99401-99404, or G0444.
The appropriate ICD-10 code to report these services is Z13.30, Z13.31, Z13.32 and Z13.39.
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.
Effective August 1, 2023 – December 2024
The USPSTF recommends screening for depression in the general adult population, including pregnant and postpartum women. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.
Screening for anxiety in adult women, including those who are pregnant or postpartum, is covered for members of “non-grandfathered” plans on an annual basis without cost sharing (i.e., deductible, co-pay, or co-insurance).
Codes that may be used to report these services include 96127, 96160, 96161, 99385-99387, 99395-99397, 99401-99404, or G0444.
The appropriate ICD-10 code to report these services is Z13.30, Z13.31, Z13.32 and Z13.39.
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.
Effective January 2023 – July 2023
The USPSTF recommends screening for depression in the general adult population, including pregnant and postpartum women. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.
Screening for anxiety in adult women, including those who are pregnant or postpartum, is covered for members of “non-grandfathered” plans on an annual basis without cost sharing (i.e., deductible, co-pay, or co-insurance).
Codes that may be used to report these services include 99385-99387, 99395-99397, 99401-99404, or GO444.
The appropriate ICD-10 code to report these services is Z13.30, Z13.31, Z13.32 and Z13.39.
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.
Effective Prior to January 2023
The USPSTF recommends screening for depression in the general adult population, including pregnant and postpartum women. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.
Codes that may be used to report these services include 99385-99387, 99395-99397, 99401-99404, or GO444.
The appropriate ICD-10 code to report these services is Z13.30, Z13.31, Z13.32 and Z13.39.
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.
Effective Prior to January 2019
The USPSTF recommends screening for depression in the general adult population, including pregnant and postpartum women. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.
Codes that may be used to report these services include 99385-99387, 99395-99397, 99401-99404, or GO444.
The appropriate ICD-9 code to report these services are V82.89 and V79.0.
The appropriate ICD-10 code to report these services is Z13.89.
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.
Effective Prior to July 2016
The USPSTF recommends screening adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up. Simple assessment of depression for screening purposes is considered part of an evaluation/management service and typically would not be the primary purpose for the service. Codes that may be used to report these services include 99385-99387, 99395-99397, 99401-99404, or GO444.
The appropriate ICD-9 code to report these services are V82.89 and V79.0.
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.
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| Rationale: |
The U.S. Preventive Services Task Force (USPSTF) found good evidence that treating depressed adults and older adults identified through screening in primary care settings with antidepressants, psychotherapy, or both decreases clinical morbidity.
The USPSTF found good evidence that programs combining depression screening and feedback with staff assisted depression care supports improve clinical outcomes in adults and older adults.
The USPSTF found fair evidence that screening and feedback alone without staff-assisted care supports do not improve clinical outcomes in adults and older adults.
This recommendation applies to nonpregnant adults, including older adults. It does not apply to children and adolescents, who are considered a separate population.
Individuals at increased risk for depression are considered at risk throughout their lifetime. Groups at increased risk include persons with other psychiatric disorders, including substance misuse; persons with a family history of depression; persons with chronic medical diseases; and persons who are unemployed or of lower socioeconomic status. Also, women are at increased risk compared with men. Significant depressive symptoms are associated with common life events in older adults, including medical illness, cognitive decline, bereavement, and institutional placement in residential or inpatient settings. However, the presence of risk factors alone cannot distinguish depressed patients from nondepressed patients.
The USPSTF reviewed evidence about the accuracy of screening instruments in identifying depressed adults in 2002. Many formal screening tools are available, including instruments designed specifically for older adults. Asking 2 simple questions about mood and anhedonia ("Over the past 2 weeks, have you felt down, depressed, or hopeless?" and "Over the past 2 weeks, have you felt little interest or pleasure in doing things?") may be as effective as using more formal instruments. There is little evidence to recommend 1 screening method over another; therefore, clinicians may choose the method most consistent with their personal preference, the patient population being served, and the practice setting.
All positive screening tests should trigger full diagnostic interviews that use standard diagnostic criteria (that is, those from the updated Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) to determine the presence or absence of specific depressive disorders, such as MDD or dysthymia. The severity of depression and comorbid psychological problems (for example, anxiety, panic attacks, or substance abuse) should be addressed.
"Staff-assisted depression care supports" refers to clinical staff that assist the primary care clinician by providing some direct depression care, such as care support or coordination, case management, or mental health treatment.
The optimum interval for screening for depression is unknown. Recurrent screening may be most productive in patients with a history of depression, unexplained somatic symptoms, comorbid psychological conditions (for example, panic disorder or generalized anxiety), substance abuse, or chronic pain.
The potential harms of screening include false-positive results, the inconvenience of additional diagnostic workup, the costs and adverse effects of treatment of patients who are incorrectly identified as being depressed, and potential adverse effects of labeling. The evidence review found no evidence on any of these potential harms of screening (O’Conner et. al., 2009)
2017 Update
This recommendation was updated in January 2016 (Siu, 2016). The following is a summary of information included in the recommendation. This recommendation applies to adults 18 years and older. It does not apply to children and adolescents, who are addressed in a separate USPSTF recommendation statement and separate policy.
2023 Update
The current HRSA guidelines for screening for anxiety states: WPSI recommends screening for anxiety in adolescent and adult women, including those who are pregnant or postpartum. Optimal screening intervals are unknown and clinical judgement should be used to determine screening frequency. Given the high prevalence of anxiety disorders, lack of recognition in clinical practice, and multiple problems associated with untreated anxiety, clinicians should consider screening women who have not been recently screened (HRSA, 2023).
2024 Update
The USPSTF updated their recommendation, The USPSTF recommends screening for anxiety disorders in adults 64 years of age or younger, including pregnant and postpartum persons (Grade B) (USPSTF, 2024).
Anxiety disorders are commonly occurring mental health conditions. Anxiety disorders include generalized anxiety disorder, social anxiety disorder, panic disorder, separation anxiety disorder, phobias, selective mutism, and anxiety not otherwise specified (O’Connor, 2022). Anxiety disorders are often unrecognized in primary care settings and years-long delays in treatment initiation occur (O’Connor, 2022; Mitchell, 2009; Roberge, 2015; Wang, 2007). Anxiety can be a chronic condition characterized by periods of remission and recurrence. However, full recovery may occur (O’Connor, 2022; Bandelow, 2015).
According to US data collected from 2001 to 2002, the lifetime prevalence of anxiety disorders in adults was 26.4% for men and 40.4% for women (Kessler, 2012). Generalized anxiety disorder has an estimated prevalence of 8.5% to 10.5% during pregnancy and 4.4% to 10.8% during the postpartum period (Misri, 2015). Anxiety disorders typically begin in childhood and early adulthood, and symptoms appear to decline with age. Some community-based epidemiology studies indicate that rates of anxiety disorders are lowest in adults aged 65 to 79 years, but these data are outdated (O’Connor, 2022; Bandelow, 2015).
The USPSTF concludes with moderate certainty that screening for anxiety in adults, including pregnant and postpartum persons, has a moderate net benefit.
The USPSTF concludes that the evidence is insufficient on screening for anxiety disorders in older adults, defined as 65 years or older. Evidence on the accuracy of screening tools, as well as the relative benefits and harms of screening and treatment of screen-detected older adults with anxiety disorders, is lacking. Therefore, the balance of benefits and harms cannot be determined and more research is necessary.
This recommendation applies to adults (19 years or older), including pregnant and postpartum persons, who do not have a diagnosed mental health disorder and are not showing recognized signs or symptoms of anxiety disorders.
Anxiety disorders are characterized by disproportionate and constant fear over everyday events accompanied by behavioral and somatic complaints (e.g., restlessness, fatigue, problems concentrating, irritability, or sleep problems) (APA, 2013). The Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) recognizes the following types of anxiety disorders: generalized anxiety disorder, social anxiety disorder, panic disorder, agoraphobia, specific phobias, separation anxiety disorder, selective mutism, substance/medication-induced anxiety disorder, anxiety disorder due to another medical condition, and anxiety not otherwise specified (APA, 2013).
Risk factors for anxiety disorders include sociodemographic factors, psychosocial factors, and physical and mental health factors such as marital status (widowed or divorced), stressful life events, smoking and alcohol use, other mental health conditions, or a parental history of mental disorders (O’Connor, 2022; Moreno-Peral, 2014). Demographic factors such as low socioeconomic status and female sex are associated with higher rates of anxiety disorders (O’Connor, 2022). Black persons and individuals of non-Hispanic ethnicity are at increased risk of anxiety disorders due to social, rather than biological, factors. Anxiety and depressive disorders often overlap. One cohort study found that 67% of individuals with a depressive disorder also had a current anxiety disorder, and 75% had a lifetime comorbid anxiety disorder (O’Connor, 2022; Lamers, 2011).
Brief tools have been developed that screen for anxiety disorders and are available for use in primary care. Selected screening tools widely used in the US include versions of the Generalized Anxiety Disorder (GAD) scale, Edinburgh Postnatal Depression Scale (EPDS) anxiety subscale, Geriatric Anxiety Scale (GAS), and the Geriatric Anxiety Inventory (GAI) (O’Connor, 2022). Some instruments that are used for screening for anxiety disorders were initially developed for purposes other than screening, such as supporting diagnosis, assessing severity, or evaluating response to treatment. Anxiety screening tools alone are insufficient to diagnose anxiety disorders. If a screening test result is positive for an anxiety disorder, a confirmatory diagnostic assessment is needed.
There is little evidence regarding optimal timing for screening, or screening interval, for both the perinatal and general adult populations; more evidence on both timing and screening interval is needed for all adult populations. A pragmatic approach in the absence of evidence might include screening all adults who have not been screened previously and using clinical judgment in considering risk factors, comorbid conditions, and life events to determine if additional screening of high-risk patients is warranted. Ongoing assessment of risks that may develop during pregnancy and the postpartum period is also a reasonable approach.
Potential barriers to screening include clinician knowledge and comfort level with screening, inadequate systems to support screening or to manage positive screening results, and impact on care flow, given the time constraints faced by primary care clinicians. Clinicians should be cognizant to stigma issues associated with mental health diagnoses and should aim to develop trusting relationships with patients, free of implicit bias, by being sensitive to cultural issues (O’Connor, 2022).
Anxiety disorders often have onset during childhood and adolescence (median age, 11 years). The prevalence of anxiety disorders decreases in the middle and older adult years and is lowest among adults aged 65 to 79 years (O’Connor, 2022). Anxiety disorders have long-term effects that include impaired quality of life and functioning and sizeable economic costs.
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| References: |
Health Resources & Services Administration (HRSA).(2023) Women’s Preventive Services Guidelines. Accessed 1/5/2023. https://www.hrsa.gov/womens-guidelines. O'Connor EA, Whitlock EP, Beil TL, Gaynes BN(2009) Screening for depression in adult patients in primary care settings: a systematic evidence review. Ann Intern Med 2009;151:793-803. PPACA & HECRA: Public Laws 111-148 & 111-152. The Patient Protection and Affordable Care Act Screening for depression in Adults, Dec 2009: U.S. Preventive Services Task Force http://www.uspreventiveservicestaskforce.org/uspstf09/adultdepression/addeprrs.htm Siu AL, and the US Preventive Services Task Force (USPSTF).(2016) Screening for Depression in AdultsUS Preventive Services Task Force Recommendation Statement. JAMA. 2016;315(4):380-387. |
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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 © 2025 American Medical Association. |
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