Coverage Policy Manual - Arkansas Blue Cross and Blue Shield

PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: DEPRESSION AND ANXIETY SCREENING IN ADOLESCENTS

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 January 1, 2024

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 children and adolescents aged 8 to 18 years 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 August 1, 2023 – December 31, 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.

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).

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.

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.

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.

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.

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).

2024 Update

Anxiety disorder, a common mental health condition in the US, comprises a group of related conditions characterized by excessive fear or worry that present as emotional and physical symptoms (Viswanathan, 2022; APA, 2013; Viswanathan, 2022). The 2018-2019 National Survey of Children’s Health (NSCH) found that 7.8% of children and adolescents aged 3 to 17 years had a current anxiety disorder (U.S. DOC, 2021). Anxiety disorders in childhood and adolescence are associated with an increased likelihood of a future anxiety disorder or depression (Viswanathan, 2022; Viswanathan, 2022).

The US Preventive Services Task Force (USPSTF) concludes with moderate certainty that screening for anxiety in children and adolescents aged 8 to 18 years has a moderate net benefit (USPSTF, 2022).

The USPSTF concludes that the evidence is insufficient on screening for anxiety in children 7 years or younger. Evidence on the accuracy of screening tools and the effects of screening and treatment in this younger age group is lacking, and the balance of benefits and harms cannot be determined.

This recommendation applies to children and adolescents 18 years or younger who do not have a diagnosed anxiety disorder or are not showing recognized signs or symptoms of anxiety.

Anxiety disorders are characterized by greater duration or intensity of impairment of a stress response. The Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) recognizes 7 different types of anxiety disorders in children and adolescents: generalized anxiety disorder (GAD), social anxiety disorder, panic disorder, agoraphobia, specific phobias, separation anxiety disorder, and selective mutism (APA, 2013).

Risk factors for anxiety disorders include genetic, personality, and environmental factors, such as attachment difficulties, interparental conflict, parental overprotection, early parental separation, and child maltreatment. Demographic factors such as poverty and low socioeconomic status are also associated with higher rates of anxiety disorders (Viswanathan, 2022; Viswanathan, 2022; Ehrenreich, 2008; Beesdo, 2010; Yap, 2015; Bogels, 2006; Lernstra, 2008; Beesdo-Baum, 2009; Tandon, 2009; Costello, 2003). The National Survey on LGBTQ Youth Mental Health reported that 72% of lesbian, gay, bisexual, transgender, and queer youth and 77% of transgender and nonbinary youth described GAD symptoms (The Trevor Project, 2021). According to the 2016 NSCH, anxiety conditions were most common in older children and adolescents (aged 12 to 17 years) compared with younger children (11 years or younger) (Ghandour, 2019).

Previous studies suggested that Black youth may have lower rates of mental health disorders compared with White youth. The 2016 NSCH also found that anxiety conditions were more common in non-Hispanic White children compared with children of other racial or ethnic backgrounds (Ghandour, 2019). However, recent cohorts of Black children or adolescents have reported a higher prevalence of anxiety disorders than in the past (Louie, 2018). Multiple factors, ranging from socioeconomic status, childhood adversity, family structure, and neighborhood effects, may influence patterns of prevalence by race or ethnicity (Viswanathan, 2022; Viswanathan, 2022). Adverse childhood experiences influence the likelihood of experiencing mental health conditions such as anxiety. Adverse childhood experiences may result from a complex interaction of familial, peer, or societal factors, including racial discrimination. These adverse childhood experiences may be blatant or subtle (e.g., microaggressions) but are potentially traumatic events that, in the context of historic trauma, structural racism, and biopsychological vulnerability, can worsen mental health outcomes (Viswanathan, 2022; Viswanathan, 2022; Bernard). Combined with lower engagement with mental health services, adverse childhood experiences can result in high levels of unmet mental health needs in Black youth (Viswanathan, 2022; Viswanathan, 2022; Lu, 2020; Lu, 2017; Merikangas, 2011; Howell, 2008; Emergency Task Force on Black Youth Suicide and Mental Health, 2020). Similar patterns of historic trauma, adverse childhood experiences, and substance abuse may also explain higher rates of mental health disorders in Native American/Alaska Native youth (Viswanathan, 2022; Viswanathan, 2022).

Anxiety screening instruments that have been assessed by the USPSTF are heterogeneous. Some screening instruments are designed to assess for a specific anxiety disorder (e.g., the Social Phobia and Anxiety Inventory for Children, which screens for social phobia and anxiety disorder), while others are designed to assess several anxiety disorders. Broader screening instruments used to identify children with several different anxiety disorders include the Screen for Child Anxiety Related Disorders (SCARED) (global anxiety and any anxiety disorder) and the Patient Health Questionnaire–Adolescent (GAD and panic disorder).

Many instruments that screen for anxiety were initially developed for epidemiologic studies for surveillance or to evaluate response to treatment. Not all of the screening instruments are feasible for use in primary care settings because of length (Viswanathan, 2022; Viswanathan, 2022). Currently, only 2 screening instruments are widely used in clinical practice for detecting anxiety: SCARED and Social Phobia Inventory.

Anxiety screening tools alone are not sufficient to diagnose anxiety. If the screening test is positive for anxiety, a confirmatory diagnostic assessment and follow-up is required.

The USPSTF found no evidence on appropriate or recommended screening intervals, and the optimal interval is unknown. Repeated screening may be most productive in adolescents with risk factors for anxiety. Opportunistic screening may be appropriate for adolescents, who may have infrequent health care visits.

Treatment for anxiety disorders can include psychotherapy, pharmacotherapy, a combination of both, or collaborative care (Ghandour, 2019). Several psychotherapy approaches have been used to treat anxiety; however, cognitive behavioral therapy is the most commonly used approach (Louie, 2018; Bernard, 2021; Lu, 2020). Duloxetine, a serotonin–norepinephrine reuptake inhibitor, is the only medication approved by the US Food and Drug Administration for treatment of GAD in children 7 years or older. Other medications have also been reported as being prescribed off-label for treatment of anxiety in youth (Viswanathan, 2022; Viswanathan, 2022).

CPT/HCPCS:

96127	Brief emotional/behavioral assessment (eg, depression inventory, attention deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument
96160	Administration of patient focused health risk assessment instrument (eg, health hazard appraisal) with scoring and documentation, per standardized instrument
96161	Administration of caregiver focused health risk assessment instrument (eg, depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument
99383	Initial 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; late childhood (age 5 through 11 years)
99384	Initial 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; adolescent (age 12 through 17 years)
99385	Initial 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
99393	Periodic 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; late childhood (age 5 through 11 years)
99394	Periodic 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; adolescent (age 12 through 17 years)
99395	Periodic 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
99401	Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes
99402	Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes
99403	Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 45 minutes
99404	Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 60 minutes
G0444	Annual depression screening, 5 to 15 minutes

References:

American Psychiatric Association (APA).(2013) Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2013.

Beesdo K, Pine DS, Lieb R, Wittchen HU.(2010) Incidence and risk patterns of anxiety and depressive disorders and categorization of generalized anxiety disorder. Arch Gen Psychiatry. 2010;67(1):47-57.

Beesdo-Baum K, Höfler M, Gloster AT, et al.(2009) The structure of common mental disorders: a replication study in a community sample of adolescents and young adults. Int J Methods Psychiatr Res. 2009;18(4):204-220.

Bernard DL, Calhoun CD, Banks DE, Halliday CA, Hughes-Halbert C, Danielson CK.(2021) Making the "C-ACE" for a culturally-informed adverse childhood experiences framework to understand the pervasive mental health impact of racism on Black youth. J Child Adolesc Trauma. 2021;14(2):233-247.

Bögels SM, Brechman-Toussaint ML.(2006) Family issues in child anxiety: attachment, family functioning, parental rearing and beliefs. Clin Psychol Rev. 2006;26(7):834-856.

Costello EJ, Mustillo S, Erkanli A, et al.(2003) Prevalence and development of psychiatric disorders in childhood and adolescence. Arch Gen Psychiatry. 2003;60(8):837-844.

Ehrenreich JT, Santucci LC, Weiner CL.(2008) Separation anxiety disorder in youth: phenomenology, assessment, and treatment. Psicol Conductual. 2008;16(3):389-412.

Emergency Task Force on Black Youth Suicide and Mental Health.(2020) Ring the Alarm: The Crisis of Black Youth Suicide in America. Published 2020. Accessed August 30, 2022. https://watsoncoleman.house.gov/uploadedfiles/full_taskforce_report.pdf

Ghandour RM, Sherman LJ, Vladutiu CJ, et al.(2019) Prevalence and treatment of depression, anxiety, and conduct problems in US children. J Pediatr. 2019;206:256-267.

Health Resources & Services Administration (HRSA).(2023) Women’s Preventive Services Guidelines. Accessed 1/5/2023. https://www.hrsa.gov/womens-guidelines.

Howell E, McFeeters J.(2008) Children's mental health care: differences by race/ethnicity in urban/rural areas. J Health Care Poor Underserved. 2008;19(1):237-247.

Lemstra M, Neudorf C, D’Arcy C, Kunst A, Warren LM, Bennett NR.(2008) A systematic review of depressed mood and anxiety by SES in youth aged 10–15 years. Can J Public Health. 2008;99(2):125-129.

Louie P, Wheaton B.(2018) Prevalence and patterning of mental disorders through adolescence in 3 cohorts of Black and White Americans. Am J Epidemiol. 2018;187(11):2332-2338.

Lu W.(2017) Child and adolescent mental disorders and health care disparities: results from the National Survey of Children's Health, 2011-2012. J Health Care Poor Underserved. 2017;28(3):988-1011.

Lu W.(2020) Treatment for adolescent depression: national patterns, temporal trends, and factors related to service use across settings. J Adolesc Health. 2020;67(3):401-408.

Merikangas KR, He JP, Burstein M, et al.(2011) Service utilization for lifetime mental disorders in U.S. adolescents: results of the National Comorbidity Survey-Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2011;50(1):32-45.

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

Tandon M, Cardeli E, Luby J.(2009) Internalizing disorders in early childhood: a review of depressive and anxiety disorders. Child Adolesc Psychiatr Clin N Am. 2009;18(3):593-610.

The Trevor Project.(2021) 2021 National Survey on LGBTQ Youth Mental Health. The Trevor Project; 2021.

U.S. Department of Commerce.(2021) 2020 National Survey of Children’s Health: Topical Frequencies. U.S. Census Bureau; 2021.

U.S. Preventive Services Task Force (USPSTF).(2022) Final Recommendation Statement Anxiety in Children and Adolescents: Screening. Updated October 11, 2022. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/screening-anxiety-children-adolescents. Accessed December 7, 2023.

U.S. Preventive Services Task Force.(2021) U.S. Preventive Services Task Force Procedure Manual. Updated May 2021. Accessed August 30, 2022. https://uspreventiveservicestaskforce.org/uspstf/procedure-manual

Viswanathan M, Wallace I, Middleton JC, et al.(2022) Screening for Depression, Anxiety, and Suicide Risk in Children and Adolescents: An Evidence Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 221. Agency for Healthcare Research and Quality; 2022. AHRQ publication No. 22-05293-EF-1.

Viswanathan M, Wallace IF, Cook Middleton J, et al.(2022) Screening for anxiety in children and adolescents: evidence report and systematic review for the US Preventive Services Task Force. JAMA. Published October 11, 2022.

Yap MB, Jorm AF.(2015) Parental factors associated with childhood anxiety, depression, and internalizing problems: a systematic review and meta-analysis. J Affect Disord. 2015;175:424-40.

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.