| Coverage Policy Manual | |
| Policy #: | 2012032 |
| Category: | PPACA Preventive |
| Initiated: | August 2012 |
| Last Review: | April 2023 |
|
|
|
|||||||||||
| PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: GESTATIONAL AND POSTPARTUM DIABETES SCREENING | |
|
|
|
| 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 September 23, 2010. Preventive services that have strong scientific evidence of their health benefits must be covered and plans can no longer charge a patient a copayment, coinsurance or deductible for these services when they are delivered by a network provider. A component of the law was a requirement that all “non-grandfathered” health insurance plans are required to provide coverage without cost sharing consistent with the Health Resources and Services Administration ‘s (HRSA’s) Women's Preventive Services: Required Health Plan Coverage Guidelines.
The HRSA-supported health plan coverage guidelines were developed by the Department of Health and Human Services (HHS) commissioned Institute of Medicine (IOM). HHS commissioned an IOM study to review what preventive services are necessary for women’s health and well-being and should be considered in the development of comprehensive guidelines for preventive services for women. HRSA supports the IOM’s recommendations on preventive services that address health needs specific to women and fill gaps in existing guidelines.
Non-grandfathered plans and issuers are required to provide coverage without cost sharing consistent with these guidelines starting August 1, 2012.
Plans are not required to provide coverage for the preventive services if they are delivered by out-of-network providers.
|
|
|
|
|
Policy/ Coverage: |
Effective January 1, 2024
Screening for gestational diabetes during pregnancy is covered for members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance, or co-pay):
The appropriate ICD-10 codes to report these services are O09.00- O09.40, O09.519, O09.529- O09.93, Z13.1, Z33.1, Z34.00- Z34.93, Z86.32.
Codes that may be used to report this service include 82947, 82950, 82951, 82952, or 83036.
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.
Screening for diabetes mellitus after pregnancy is covered for members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance, or co-pay) for women:
*Note: Initial testing should ideally occur within the first year postpartum and can occur as early as 4-6 weeks postpartum.
Women who were not screened in the first year postpartum or those with a negative initial postpartum screening test should be screened every 3 years for a minimum of 10 years after pregnancy.
For those with a positive postpartum screening test result, testing should be repeated to confirm the diagnosis of diabetes regardless of the initial testing method (e.g., oral glucose tolerance test, fasting plasma glucose, or Hemoglobin A1c).
Repeat screening for diabetes mellitus is covered for members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance, or co-pay) for women who were screened with hemoglobin A1c in the first 6 months postpartum regardless of whether screening result was positive or negative.
The appropriate ICD-10 code to report this service is Z13.1, Z39.0, Z39.1, Z39.2, Z86.32.
Codes that may be used to report this service include 82947, 82950, 82951, 82952, or 83036.
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 2019 – December 2023
Screening for gestational diabetes is covered for members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance or co-pay) for:
The appropriate ICD-10 codes to report these services are O09.00- O09.40, O09.519, O09.529- O09.93, Z13.1, Z33.1, Z34.00- Z34.93, Z86.32.
Codes that may be used to report this service include 82947, 82950, 82951, 82952, or 83036.
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.
Screening for diabetes mellitus is covered for members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance or co-pay) for women:
Positive postpartum screening test results should be confirmed regardless of the initial testing method (eg, oral glucose tolerance test, fasting plasma glucose, or Hemoglobin A1c).
Repeat screening for diabetes mellitus is covered for members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance or co-pay) for women:
The appropriate ICD-10 code to report this service is Z13.1, Z39.0, Z39.1, Z39.2, Z86.32.
Codes that may be used to report this service include 82947, 82950, 82951, 82952, or 83036.
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 gestational diabetes is covered for members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance or co-pay) for:
The appropriate ICD-9 code to report these services is V77.1. Or V22.0-V22.2 or V23.0-V23.9.
The appropriate ICD-10 codes to report these services are O09.00- O09.40, O09.519, O09.529- O09.93, Z13.1, Z34.00- Z34.93.
Codes that may be used to report this service include 82947, 82950 or 83036.
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 June 2014
Screening for gestational diabetes is covered for members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance or co-pay) for:
The appropriate ICD-9 code to report these services is V77.1. Or V22.0-V22.2 or V23.0-V23.9.
Codes that may be used to report this service include 82947, 82950 or 83036.
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 Committee on Preventive Services for Women identified two gaps in the preventive services already addressed in the existing guidelines. These services include screening for diabetes mellitus in all women and screening for gestational diabetes.
The HRSA-supported health plan coverage guidelines recommend screening for gestational diabetes in pregnant women between 24 and 28 weeks of gestation and at the first prenatal visit for pregnant women identified to be at high risk for diabetes. According to the committee, this recommendation is based on current federal practice policy and current clinical practice guidelines from the AAFP and ACOG.
The committee did not find sufficient evidence to recommend screening for diabetes in all women.
2014 Update
In January 2014, the USPSTF released a Grade B recommendation for screening for gestational diabetes mellitus in asymptomatic pregnant women after 24 weeks of gestation.
The USPSTF did not recommend screening for gestational diabetes before 24 weeks of gestation citing insufficient evidence. Additionally, the balance of benefits and harms of screening could not be determined.
The coverage statement has been changed to address this new recommendation.
2019 Update
Effective January 2019, the Committee on Preventive Services for Women recommends screening in the postpartum period for women with a history of gestational diabetes.
The coverage statement has been changed to address this new recommendation.
2023 Update
HRSA updated their guidelines effective January 1, 2024, for gestational diabetes screening (HRSA, 2023). The guideline for screening during pregnancy states: WPSI recommends screening pregnant women for gestational diabetes mellitus after 24 weeks of gestation (preferably between 24 and 28 weeks of gestation) to prevent adverse birth outcomes. WPSI recommends screening pregnant women with risk factors for type 2 diabetes or GDM before 24 weeks of gestation—ideally at the first prenatal visit. The guideline for screening for diabetes after pregnancy states: WPSI recommends screening for type 2 diabetes in women with a history of gestational diabetes mellitus (GDM) who are not currently pregnant and who have not previously been diagnosed with type 2 diabetes. Initial testing should ideally occur within the first year postpartum and can be conducted as early as 4–6 weeks postpartum. Women who were not screened in the first year postpartum or those with a negative initial postpartum screening test result should be screened at least every 3 years for a minimum of 10 years after pregnancy. For those with a positive screening test result in the early postpartum period, testing should be repeated at least 6 months postpartum to confirm the diagnosis of diabetes regardless of the type of initial test (e.g., fasting plasma glucose, hemoglobin A1c, oral glucose tolerance test). Repeat testing is also indicated for women screened with hemoglobin A1c in the first 6 months postpartum regardless of whether the test results are positive or negative because the hemoglobin A1c test is less accurate during the first 6 months postpartum.
|
|
|
|
| CPT/HCPCS: | |
|
|
|
| References: |
Health Resources & Services Administration (HRSA).(2023) Women’s Preventive Services Guidelines. Accessed 12/18/2023. https://www.hrsa.gov/womens-guidelines. IOM (Institute of Medicine).(2011) Clinical Preventive Services for Women: Closing the Gaps. Washington, DC: The National Acadamies Press. |
|
|
|
|
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. |
|