Coverage Policy Manual - Arkansas Blue Cross and Blue Shield

PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: SKIN CANCER, BEHAVIORAL COUNSELING FOR PREVENTION

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 and those preventive services recommended by the Health Resources and Services Administration (HSRA).

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:

Behavioral counseling regarding exposure to ultraviolet radiation to reduce risk for skin cancer is covered for members of “non-grandfathered” plans with fair skin aged 6 months to 24 years. Brief counseling may be delivered by primary care clinicians. This benefit is limited to 1 session, per calendar or contract year.

The appropriate ICD-10 codes to report these services are Z00.121, Z00.129, Z00.00-Z00.01 or Z00.8.

The codes used to report this service are 99381-99385 or 99391-99395. 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.

Rationale:

The USPSTF recommends counseling children, adolescents, and young adults aged 6 months to 24 years who have fair skin about minimizing their exposure to ultraviolet radiation to reduce risk for skin cancer.

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of counseling adults older than 24 years about minimizing risks to prevent skin cancer.

The USPSTF recommendation includes the following information:

The recommendation applies to all asymptomatic persons with no history of skin cancer. Because most trials of skin cancer counseling only include people with a fair skin type, the recommendation for counseling of children, adolescents, and young adults aged 6 months to 24 years is limited to this population.
Counseling adults is of uncertain potential benefit because of the unknown effectiveness of counseling interventions in changing behavior and because of the less secure link between behavior change in adulthood and risk for skin cancer. UV exposure after age 35 years may contribute less to one's lifetime risk for skin cancer than exposure at a younger age.
Skin type can be visually assessed by primary care clinicians. Fair skin type can be defined by eye and hair color; freckling; and historical factors, such as usual reaction to sun exposure (always or usually burning or infrequently tanning).
Effective interventions were generally of low intensity and almost entirely done during the primary care interaction or visit. Successful counseling interventions used cancer prevention or appearance-focused messages to reach specific audiences.
Various education materials using different media were found to be effective in counseling children, adolescents, and young adults. Several organizations that focus on sun safety or skin cancer prevention have created age-appropriate educational materials, many of which include appearance-based messages.
Primary care practitioners may consider which materials can be easily implemented in their setting and for their population. The time required by the clinician to provide brief counseling is the main cost of these services.

CPT/HCPCS:

99381	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; infant (age younger than 1 year)
99382	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; early childhood (age 1 through 4 years)
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
99391	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; infant (age younger than 1 year)
99392	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; early childhood (age 1 through 4 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

References:

Moyer VA; on behalf of the U.S. Preventive Services Task Force.(2012) Behavioral counseling to prevent skin cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012 May 7. [Epub ahead of print].

PPACA & HECRA: Public Laws 111-148 & 111-152. The Patient Protection and Affordable Care Act

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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