Coverage Policy Manual
Policy #: 2012044
Category: PPACA Preventive
Initiated: August 2012
Last Review: May 2023
  PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: BICYCLE HELMET USE FOR CHILDREN & ADOLESCENTS, 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 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” (AAP, 2008).
 
Bright Futures describes its guidelines as “evidence informed rather than fully evidence driven” (Hagan, 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:
Counseling for bicycle helmet use at well-child visits is covered for members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance or co-pay).
 
The appropriate ICD-10 codes to report these services are Z00.00, Z00.01, Z00.8, Z00.121, Z00.129, and Z71.89.
 
Codes that may be used to report this service include CPT 99381, 99382, 99383, 99384, 99385, 99391, 99392, 99393, 99394, 99395 or 99401.  
 
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:
This policy is based on the Third Edition of Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents (Hagan, 2008).  
 
The guidelines include an entire section on the role of the health care professional in the promotion of safety and prevention of injury. “Ensuring that a child remains safe from harm or injury during the long journey from infancy through adolescence is a constant task that requires the participation of parents and the many other adults who care for and help to raise children, and, of course, of the children themselves. Health care professionals have long recognized the importance of safety and injury prevention counseling as a tool to help educate and motivate parents in keeping their children safe” (Hagan, 2008).
 
The Anticipatory Guidance section of the Bright Futures Handbook (Tanski, 2010) gives the following information regarding screening and counseling on bicycle helmet use:
 
    • Every year about 450,000 children are treated in emergency departments for bicycle-related injuries.
    • It is well established that bicycle helmets are effective in preventing head injuries associated with bicycling.
    • Counseling and safety programs can increase helmet use.
    • During the counseling session, encourage the parents to ensure the helmet meets the safety requirements of the Consumer Product Safety Commission and that the helmet fits the child properly.  The parents should be urged to require the child to wear the helmet every time the child rides a bike. Additionally, the parents should be encouraged to serve as a role model to their child by wearing a helmet themselves when riding a bicycle.
    • Materials from the American Academy of Pediatrics (AAP) Injury Prevention Program (TIPP), including the Framingham Safety Survey, can be used to aid in the counseling of the parent and child (AAP, 1994).
 
 
 

CPT/HCPCS:
99381Initial 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)
99382Initial 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)
99383Initial 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)
99384Initial 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)
99385Initial 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
99392Periodic 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)
99393Periodic 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)
99394Periodic 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)
99395Periodic 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
99401Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes

References: American Academy of Pediatrics Committee and Section on Injury, Violence and Poison Prevention. TIPP: A guide to Safety Counseling in Office Practice. Elk Grove Village, IL: American Academy of Pediatrics; 1994.

Hagan JF, Shwa JS, Duncan PM, eds.(2008) Bright Futures: Guidelines for health supervision of infants, children and adolescents, 3rd ed. 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.

Tanski S, Garfunkel LC, Duncan PM, Weitzman M, eds.(2010) Performing Preventive Services: A Bright Futures Handbook. American Academy of Pediatrics.


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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