Coverage Policy Manual
Policy #: 2011043
Category: PPACA Preventive
Initiated: September 2010
Last Review: April 2024
  PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: DEPRESSION AND ANXIETY SCREENING, 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:
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 August 1, 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 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.
 
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.
 
    • The USPSTF recommends screening in all adults regardless of risk factors. However, a number of factors are associated with an increased risk of depression. Among general adult populations, prevalence rates vary by sex, age, race/ethnicity, education, marital status, geographic location, and employment status. Women, young and middle-aged adults, and nonwhite persons have higher rates of depression than their counterparts, as do persons who are undereducated, previously married, or unemployed. Other groups who are at increased risk of developing depression include persons with chronic illnesses (eg, cancer or cardiovascular disease), other mental health disorders (including substance misuse), or a family history of psychiatric disorders.
    • Among older adults, risk factors for depression include disability and poor health status related to medical illness, complicated grief, chronic sleep disturbance, loneliness, and a history of depression. However, the presence or absence of risk factors alone cannot distinguish patients with depression from those without depression.
    • Risk factors for depression during pregnancy and postpartum include poor self-esteem, child-care stress, prenatal anxiety, life stress, decreased social support, single/unpartnered relationship status, history of depression, difficult infant temperament, previous postpartum depression, lower socioeconomic status, and unintended pregnancy.
    • Commonly used depression screening instruments include the Patient Health Questionnaire (PHQ) in various forms and the Hospital Anxiety and Depression Scales in adults, the Geriatric Depression Scale in older adults, and the Edinburgh Postnatal Depression Scale (EPDS) in postpartum and pregnant women. All positive screening results should lead to additional assessment that considers severity of depression and comorbid psychological problems (eg, anxiety, panic attacks, or substance abuse), alternate diagnoses, and medical conditions.
    • There is little evidence regarding the optimal timing for screening. The optimum interval for screening for depression is also unknown; more evidence for all populations is needed to identify ideal screening intervals. A pragmatic approach in the absence of data might include screening all adults who have not been screened previously and using clinical judgment in consideration of risk factors, comorbid conditions, and life events to determine if additional screening of high-risk patients is warranted.
 
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).
CPT/HCPCS:
96127Brief emotional/behavioral assessment (eg, depression inventory, attention deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument
96160Administration of patient focused health risk assessment instrument (eg, health hazard appraisal) with scoring and documentation, per standardized instrument
96161Administration of caregiver focused health risk assessment instrument (eg, depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument
99385Initial 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; 18 39 years
99386Initial 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; 40 64 years
99387Initial 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; 65 years and older
99395Periodic comprehensive preventive medicine reevaluation 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, established patient; 18 39 years
99396Periodic comprehensive preventive medicine reevaluation 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, established patient; 40 64 years
99397Periodic comprehensive preventive medicine reevaluation 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, established patient; 65 years and older
99401Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes
99402Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes
99403Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 45 minutes
99404Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 60 minutes
G0444Annual depression screening, 5 to 15 minutes
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.
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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