Coverage Policy Manual
Policy #: 2012038
Category: PPACA Preventive
Initiated: August 2012
Last Review: August 2023

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.

The following lead screening is covered for infant and child members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance or co-pay):
    • Screening at the 6-month well-child visit for children who are positive on risk screening questions.
    • Routine screening for children through age 6 years from high prevalence areas.
    • Selective screening for children through age 6 years from low prevalence areas. 
The appropriate ICD-10 codes to report these services are Z00.00, Z00.01, Z00.121, Z00.129 or Z13.88.
Codes that may be used to report this service include CPT 83655.  
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.


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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