Coverage Policy Manual
Policy #: 2012036
Category: PPACA Preventive
Initiated: August 2012
Last Review: June 2022
  PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: ANEMIA, SCREENING IN INFANTS, CHILDREN AND 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.  Additionally, the law requires coverage of Bright Futures recommendations for children from the American Academy of Pediatrics, preventive services for women outlined by the Health Resources and Services Administration’s (HRSA’s) Women’s Preventive Services: Required Health Plan Coverage Guidelines and all vaccinations recommended by the Advisory Committee for Immunization Practices (ACIP) of the Centers for Disease Control and Prevention.
 
Plans are not required to provide coverage for the preventive services if they are delivered by out-of-network providers.
 
Bright Futures was established by the Health and Human Services (HHS) Health Resources and Services Administration’s Maternal and Child Health Bureau with the mission to “promote and improve the health, education, and wellbeing of infants, children, adolescents, families and communities” (Hagan, 2008).
 
Bright Futures describes its guidelines as “evidence informed rather than fully evidence driven” (AAP, 2008). Unlike the USPSTF, Bright Futures does not assign grades to recommendations that do not definitively recommend for or against a particular preventive service. Rather than leave gaps in the recommendations, Bright Futures supplements evidence with experience and expert opinion to ensure that definitive guidance is given (IOM, 2011).
 
The following policy is based on the Bright Futures recommendation for this preventive service.
 

Policy/
Coverage:
Effective June 2015
The following screening for anemia is covered for all infant, children and adolescent members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance or co-pay):
 
  • Hemoglobin and hematocrit should be screened for at the 4-month well-child visit in infants who are preterm or who are low birth weight infants, and those infants not on iron-fortified formula.
  • Hemoglobin and hematocrit should be screened for routinely at the 12-month well-child visit.
  • Hemoglobin & hematocrit should be screened selectively for children and adolescents who are positive for risk screening questions at 15 month – 21 year visits. 
 
The appropriate ICD-10 code to report this service is Z13.0
 
Codes that may be used to report this service include CPT 85014 or 85018.
 
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 June 2015
 
The following screening for anemia is covered for all infant, children and adolescent members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance or co-pay):
 
    • Hemoglobin and hematocrit should be screened for at the 4-month well-child visit in infants who are preterm or who are low birth weight infants, and those infants not on iron-fortified formula.
    • Hemoglobin and hematocrit should be screened for routinely at the 12-month well-child visit.
    • Hemoglobin & hematocrit should be screened selectively for children and adolescents who are positive for risk screening questions at the 3-21 year visits.
 
The appropriate ICD-9 code to report these services is V78.0.
 
Codes that may be used to report this service include CPT 85014 or 85018.
 
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.
 
 

CPT/HCPCS:
85014Blood count; hematocrit (Hct)
85018Blood count; hemoglobin (Hgb)

References: Hagan JF, Shwa JS, Duncan PM, eds.(2008) Bright Futures: Guidelines for health supervision of infants, children and adolescents, 3rd ed. (J. F. Hagan, J. S. Shaw, and P. M. Duncan, eds.). Elk Grove Village, IL: American Academy of Pediatrics.

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.
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