Coverage Policy Manual - Arkansas Blue Cross and Blue Shield

PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: CONTRACEPTIVE USE AND COUNSELING

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:

Food and Drug Administration-approved contraceptive methods (not including abortifacient drugs), sterilization procedures and patient education and counseling, are covered for members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance or co-pay) for all women of child-bearing potential (this includes adolescents of child-bearing potential).

There is a $0 copayment for all generic prescription contraceptives. If there is no generic in the class or subclass, then the brand contraceptive is at $0 copayment.

Emergency contraceptives for members who are less than 18 years old for Plan B and those who are less than 17 years old for Plan B One-Step is covered if a prescription is presented for coverage.

The appropriate ICD-10 codes to report these services are: Z30.02, Z30.09, Z30.011, Z30.012, Z30.013, Z30.014, Z30.015, Z30.016, Z30.017, Z30.018, Z30.019, Z30.2, Z30.40, Z30.41, Z30.42, Z30.44, Z30.45, Z30.46, Z30.49, Z30.430, Z30.431, Z30.432, Z30.433, Z30.8, Z30.9.

Codes that may be used to report this service include CPT 11976, 11980,11981, 11982, 11983, 57170, 58300, 58301, 58340, 58600, 58605, 58611, 58615, 58670, 58671, 00851, 74740, 96372, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99384, 99385, 99386, 99394, 99395, 99396, OR HCPCS G0438, G0439, S4981, S4989, S4993, A4261, A4266, A4267, A4268, A4269, J1050, J7294, J7295, J7296, J7297, J7298, J7300, J7301, J7303, J7304, and J7306 or J7307.

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:

Contraception and contraceptive counseling is not currently addressed as a preventive service recommended by the USPSTF guidelines.

The HRSA-supported health plan coverage guidelines recommend provisions for all Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling for women of childbearing potential. According to the committee, this recommendation is based on the following:

systematic reviews and peer-reviewed literature indicating that contraception and counseling reduce unintended pregnancy;
Current federal reimbursement policies provide coverage for contraception and contraceptive counseling, and most private insurers also cover contraception in their health plans;
Numerous health professional associations recommend family planning services as part of preventive care for women; And
A reduction in unintended pregnancies has been identified as a specific goal in Health People 2010 and Health People 2020.

2012 Update

ACOG (#539; Oct 2012) has issued a Committee Opinion on the use of implants and intrauterine devices for long-acting reversible contraception for adolescents:

“When choosing contraceptive methods, adolescents should be encouraged to consider Long Acting Reversible Contraception methods. Intrauterine devices and the contraceptive implant are the best reversible methods for preventing unintended pregnancy, rapid repeat pregnancy, and abortion in young women. Counseling about LARC methods should occur at all health care provider visits with sexually active adolescents, including preventive health, abortion, prenatal, and postpartum visits. Complications of IUDs and the contraceptive implant are rare and differ little between adolescents and older women. Health care providers should consider LARC methods for adolescents and help make these methods accessible to them.”

CPT/HCPCS:

00851	Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; tubal ligation/transection
11976	Removal, implantable contraceptive capsules
11980	Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets beneath the skin)
11981	Insertion, drug delivery implant (i.e., bioresorbable, biodegradable, non-biodegradable)
11982	Removal, non biodegradable drug delivery implant
11983	Removal with reinsertion, non biodegradable drug delivery implant
57170	Diaphragm or cervical cap fitting with instructions
58300	Insertion of intrauterine device (IUD)
58301	Removal of intrauterine device (IUD)
58340	Catheterization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalpingography
58600	Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral
58605	Ligation or transection of fallopian tube(s), abdominal or vaginal approach, postpartum, unilateral or bilateral, during same hospitalization (separate procedure)
58611	Ligation or transection of fallopian tube(s) when done at the time of cesarean delivery or intra abdominal surgery (not a separate procedure) (List separately in addition to code for primary procedure)
58615	Occlusion of fallopian tube(s) by device (eg, band, clip, Falope ring) vaginal or suprapubic approach
58670	Laparoscopy, surgical; with fulguration of oviducts (with or without transection)
58671	Laparoscopy, surgical; with occlusion of oviducts by device (eg, band, clip, or Falope ring)
74740	Hysterosalpingography, radiological supervision and interpretation
99202	Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.
99203	Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter.
99204	Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter.
99205	Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 60-74 minutes of total time is spent on the date of the encounter.
99212	Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter.
99213	Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.
99214	Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter.
99215	Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.
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
99386	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; 40 64 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
99396	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; 40 64 years
A4261	Cervical cap for contraceptive use
A4267	Contraceptive supply, condom, male, each
A4268	Contraceptive supply, condom, female, each
A4269	Contraceptive supply, spermicide (e.g., foam, gel), each
J1050	Injection, medroxyprogesterone acetate, 1 mg
J7294	Segesterone acetate and ethinyl estradiol 0.15mg, 0.013mg per 24 hours; yearly vaginal system, each
J7295	Ethinyl estradiol and etonogestrel 0.015mg, 0.12mg per 24 hours; monthly vaginal ring, each
J7296	Levonorgestrel releasing intrauterine contraceptive system, (kyleena), 19.5 mg
J7297	Levonorgestrel releasing intrauterine contraceptive system (liletta), 52 mg
J7298	Levonorgestrel releasing intrauterine contraceptive system (mirena), 52 mg
J7300	Intrauterine copper contraceptive
J7301	Levonorgestrel releasing intrauterine contraceptive system (skyla), 13.5 mg
J7304	Contraceptive supply, hormone containing patch, each
J7306	Levonorgestrel (contraceptive) implant system, including implants and supplies
J7307	Etonogestrel (contraceptive) implant system, including implant and supplies
S4981	Insertion of levonorgestrel releasing intrauterine system
S4989	Contraceptive intrauterine device (e.g., progestacert iud), including implants and supplies
S4993	Contraceptive pills for birth control

References:

AGOG Committee on Adolescent Health Care.(2012) Adolescents and Long-Acting Reversible Contraception: Implants and Intrauterine Devices. www.agog.org, #539, October 2012

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.