Coverage Policy Manual - Arkansas Blue Cross and Blue Shield

PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: HIGH BLOOD PRESSURE, 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:

Blood pressure screening for infants and children with specific risk factors for high blood pressure is covered up to age 2 1/2 for members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance or co-pay).

Blood pressure examination is included in the complete physical examination done routinely after age 2 1/2.

The appropriate ICD-10 codes to use to report this service are Z00.121, Z00.129, Z00.00 - Z00.01, Z13.6.

Codes that may be used to report this service include CPT 99381, 99382, 99383, 99384, 99391, 99392, 99393 or 99394.

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 Third Edition of Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents recommends selective blood pressure screening for infants and children with specific risk factors for high blood pressure through age 2 ½ (Hagan, 2008). Blood pressure measurement should be measured routinely as part of the complete physical examination in children older than 3 years.

In Performing Preventive Services, A Bright Futures Handbook (Tanski, 2008) the following information is given regarding blood pressure in children and adolescents:

High blood pressure is a growing health concern for children and adolescents.
Primary hypertension is detectable in children and adolescents and is a common problem.
The long-term health risks of hypertension can be substantial.
Obesity and hypertension are linked. Children and adolescents with hypertension are frequently overweight, with hypertension present in approximately 30% of overweight children.

Medical risk factors that warrant blood pressure screening in children younger than 3 years include the following:

A history of prematurity (<37 completed weeks), very low birth weight (<1,500 g), or other neonatal complication requiring intensive care; congenital heart disease (repaired or not repaired)
A recurrent urinary tract infection, hematuria, or proteinuria
Known renal disease or urologic malformations
A family history of congenital renal disease, solid-organ transplant, or malignancy or bone marrow transplant
Treatment with drugs known to raise blood pressure
Other systemic illnesses associated with hypertension (e.g., neurofibromatosis,tuberous sclerosis)
Evidence of increased intracranial pressure

Hypertension is defined in children and adolescents as:

Prehypertension- systolic blood pressure (SBP) and/or diastolic blood pressure (DBP) greater than or equal to 90th percentile but less than 95th percentile for age, sex, and height. Adolescents with blood pressure (BP) greater than or equal to 120/80 should be considered prehypertensive, even if 120/80 is less than the 90th percentile.
White-coat hypertension is BP at greater than or equal to 95th percentile in the office but normal outside of the office.
Hypertension- defined as SBP and/or DBP greater than 95th percentile for age, sex, and height on 3 or more occasions.

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)
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)

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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