| Coverage Policy Manual | |
| Policy #: | 2011044 |
| Category: | PPACA Preventive |
| Initiated: | September 2010 |
| Last Review: | May 2023 |
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| PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: DEPRESSION AND ANXIETY SCREENING IN ADOLESCENTS | |
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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 August 1, 2023
Screening for depression in adolescents 11-21 years of age is covered for members of “non-grandfathered” plans on an annual basis without cost sharing (i.e., deductible, co-pay, or co-insurance).
Screening for anxiety in adolescent females 13 years of age and older is covered for members of “non-grandfathered” plans on an annual basis without cost sharing (i.e., deductible, co-pay, or co-insurance).
The preventive medicine CPT codes should be used to report this service. These services include 96127, 96160, 96161, 99383-99385, 99393-99395, 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
Screening for depression in adolescents 11-21 years of age is covered for members of “non-grandfathered” plans on an annual basis without cost sharing (i.e., deductible, co-pay, or co-insurance).
Screening for anxiety in adolescent females 13 years of age and older is covered for members of “non-grandfathered” plans on an annual basis without cost sharing (i.e., deductible, co-pay, or co-insurance).
The preventive medicine CPT codes should be used to report this service. These services include 99383-99385, 99393-99395, 99401-99404, or G0444.
The appropriate ICD-10 code to report these services is Z13.30, Z13.31, 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
Screening for depression in adolescents 11-21 years of age is covered for members of “non-grandfathered” plans on an annual basis without cost sharing (i.e., deductible, co-pay or co-insurance.
The preventive medicine CPT codes should be used to report this service. These services include 99383, 99384, 99385, 99393, 99394, 99395, or 99401-99404 or G0444.
The appropriate ICD-10 code to report these services is Z13.30, Z13.31, 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
Screening for depression in adolescents 11-21 years of age is covered for members of “non-grandfathered” plans on an annual basis without cost sharing (i.e., deductible, co-pay or co-insurance.
The preventive medicine CPT codes should be used to report this service. These services include 99384, 99385, 99394, 99395, or 99401-99404 or G0444.
The appropriate ICD-9 codes to report these services are V79.0 or V82.89.
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 APRIL 2016
Screening for depression in adolescents 12-18 years of age is covered for members of “non-grandfathered” plans on an annual basis without cost sharing (i.e., deductible, co-pay or co-insurance.
The preventive medicine CPT codes should be used to report this service. These services include 99384, 99385, 99394, 99395, or 99401-99404 or G0444.
The appropriate ICD-9 code to report these services is 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) recommends screening of adolescents (12-18 years of age) for major depressive disorder (MDD) when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal), and follow-up. (B recommendation)
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening of children (7-11 years of age). (I statement)
This USPSTF recommendation addresses screening for MDD in adolescents (12-18 years of age) and children (7-11 years of age) in the general population. There is a spectrum of depressive disorders. This report focuses only on screening for MDD and does not address screening for various less-severe depressive disorders.
A variety of factors contribute to the development of MDD. Most people who develop MDD have multiple risk factors. However, risk factors for MDD can be difficult to assess. As a result, researchers have focused on identifying youth subgroups at increased risk of developing MDD. Important risk factors that can be assessed relatively accurately and reliably include parental depression, having comorbid mental health or chronic medical conditions, and having experienced a major negative life event.
Clinical depression is characterized by persistent sadness, irritability, or a loss of interest or pleasure in most activities. Additional symptoms may include social isolation, decline in school work, anger, sleep and appetite disturbances, or nonspecific pain. MDD may be present when these symptoms cluster together and persist for 2 weeks or more.
Instruments developed for primary care (Patient Health Questionnaire for Adolescents [PHQ-A] and the Beck Depression Inventory-Primary Care Version [BDI-PC]) have been used successfully in adolescents. There are limited data describing the accuracy of using MDD screening instruments in younger children (7-11 years of age).
There is adequate evidence that screening tests can accurately identify MDD in adolescents. Nine fair-quality studies of MDD screening-instrument accuracy in children and adolescents addressed 6 depression instruments. Two of these studies were conducted in primary care settings, 1 in a community setting, and 6 in school settings. Although 1 study included children younger than 10 years of age, most studies focused on adolescents 12 years of age or older.1 Studies that involved younger children demonstrated poorer performance of the screening instruments.
Two instruments demonstrated good sensitivity and specificity in primary care settings in adolescents: a sensitivity range of 73 percent for the PHQ-A to 91 percent for the BDI-PC and a specificity range from 91 percent for the BDI-PC to 94 percent for the PHQ-A.
In school settings, studies examined the Beck Depression Inventory (BDI), the Center for Epidemiologic Study-Depression Scale (CES-D), and the Revised Clinical Interview Scale (CIS-R). In this setting, cutoffs of both 11 and 16 performed reasonably to very well on the BDI, with sensitivity ranging from 84 percent to 100 percent (BDI ≥11) or 77 percent to 100 percent (BDI ≥16) and specificity ranging from 77 percent to 86 percent (BDI ≥11) or 65 percent to 96 percent (BDI ≥16). Confidence in the school-setting results is quite limited, however, because of methodologic problems within each study.
The large number of instruments and sample and setting heterogeneity makes generalization across studies difficult and may explain the wide range of performance characteristics reported (sensitivity ranged from 18 percent to 100 percent and specificity ranged from 38 percent to 97 percent). Each of the studies had methodologic limitations such as high levels of attrition, nonrandom selection, excessive delays between screening and diagnostic interviews, poor reporting of methods, small samples, and the lack of a criterion standard for the diagnosis of depression.
MDD is estimated to occur in 2.8 percent of children younger than 13 years of age. The estimated prevalence of MDD among adolescents aged 13 to 18 years is 5.6 percent, with a higher prevalence among girls than boys (5.9 percent vs 4.6 percent, respectively). Lifetime prevalence among adolescents may be as high as 20 percent. Point prevalence of MDD among adolescents is reported as ranging from 9 percent to 21 percent in primary care settings.1
MDD is associated with significant morbidity and mortality. Morbidity in children and adolescents may be demonstrated through decreased school performance, poor social functioning, early pregnancy, increased physical illness, and substance abuse. Depressed adolescents have more psychiatric and medical hospitalizations than adolescents who are not depressed. Children with depressive disorders have increased health care costs (including general medical care and mental health care) compared with children without mental health diagnoses or children with other mental health diagnoses (except conduct disorder). Depressed youth are at an increased risk of suicide, which is the third leading cause of death among those aged 15 to 24 years and the sixth leading cause among those aged 5 to 14 years. Adolescent MDD is particularly associated with increased risk of MDD occurrence in early adulthood.
2016 Update
The Bright Futures Recommendations for Preventive Pediatric Health Care includes a recommendation for screening for depression at ages 11 through 21. The coverage statement has been amended to reflect this change.
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).
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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. PPACA & HECRA: Public Laws 111-148 & 111-152. The Patient Protection and Affordable Care Act Screening and Treatment for Major Depressive Disorder in Children and Adolescents, Mar 2009: U.S. Preventive Services Task Force http://www.uspreventiveservicestaskforce.org/uspstf09/depression/chdeprrs.htm |
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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 © 2023 American Medical Association. |
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