Coverage Policy Manual
Policy #: 2012041
Category: PPACA Preventive
Initiated: August 2012
Last Review: June 2022
  PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: PREGNANCY SCREENING, SEXUALLY ACTIVE FEMALES WITHOUT CONTRACEPTION, LATE MENSES OR AMENORRHEA

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
Pregnancy screening with urine human chorionic gonadotropin testing is covered for the following female members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance or co-pay):
 
    • Sexually active females aged 11-21; AND
    • Do not practice contraception, have late menses, or have amenorrhea.  
 
The appropriate ICD 10 codes to report this service are O09.00-O09.40, O09.519, O09.529, O09.611- O09.93, Z00.00-Z00.01, Z33.1 or Z34.00-Z34.93,
 
Codes that may be used to report this service include CPT 81025 OR 84703.
 
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
Pregnancy screening with urine human chorionic gonadotropin testing is covered for the following female members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance or co-pay):
 
    • Sexually active females aged 11-21; AND
    • Do not practice contraception, have late menses, or have amenorrhea.
 
The appropriate ICD-9 code to report these services is V70.0.
 
Codes that may be used to report this service include CPT 81025 OR 84703.  
 
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 Third Edition of Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents gives the following information regarding screening for pregnancy in adolescents. (Hagan, 2008).
 
    • Decisions that are associated with sexual development in the adolescent years often have important implications for health and education, as well as current and future relationships.
    • Abstinence is the best protection from pregnancy, STIs, and the emotional distress of disrupted relationships. Knowing how to protect oneself and one’s partner from pregnancy and STIs is critical for those who are sexually active.
    • Guidance for discussions regarding pregnancy with the parent include the following:
        • Encourage abstinence from sexual activity or a return to abstinence.
        • Help your child make a plan to resist pressures to use substances or have sex.
        • Be there for him when he needs support or help.
        • Support safe activities at school, with community and faith organizations, and with volunteer groups to encourage personal and social development.
        • If you are uncomfortable talking about teen development, sexual pressures, teen pregnancy, and STIs, learn more through reliable resources.
        • Talk about relationships and sex when issues arise on television, at school, or with friends. Be open and nonjudgmental, but honest, about your personal views.
    • Guidance for discussions regarding pregnancy with the parent include the following:
        • Abstaining from sexual intercourse, including oral sex, is the safest way to prevent pregnancy and STIs.
        • Figure out ways to make sure you can carry through on your decisions regarding your sexual behaviors. Plan how to avoid risky places and relationships. For example, don’t use drugs or alcohol, because these can raise the risk of unwanted sex or other risky behaviors.
        • If you are sexually active, protect yourself and your partners from STIs and pregnancy.
 
 

CPT/HCPCS:
81025Urine pregnancy test, by visual color comparison methods
84703Gonadotropin, chorionic (hCG); qualitative

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.
CPT Codes Copyright © 2023 American Medical Association.