Coverage Policy Manual
Policy #: 2012046
Category: PPACA Preventive
Initiated: August 2012
Last Review: June 2024
  PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: WELL-CHILD VISITS, NEWBORN, INFANT, CHILDREN, ADOLESCENTS & AGES 18-21
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:
For contracts subject to Arkansas Act 316, SCREENING FOR DEPRESSION OF BIRTH MOTHERS, [individual, blanket, or any group plan, policy, or contract for healthcare services issued, renewed, or extended in this state by a healthcare insurer, health maintenance organization, hospital medical service corporation, or self-insured governmental or church plan in this state (all fully-insured and state government such as ASE/PSE, ASP)] coverage shall be provided for depression screening for birth mothers at the time of birth or within the first six weeks of birth.  For all contracts not subject to Ark law [e.g. federally chartered contracts such as ERISA groups, Federal Employee Health Benefit Program, and Medicare Advantage], these benefits will be provided as directed by PPACA.
 
Effective January 1, 2024
 
Well-child visits are covered for members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance, or co-pay) at the following intervals: Birth, first week after birth, at age 1 month, 2 months, 4 months, 6 months, 9 months, 1 year, 15 months, 18 months, 2 years, 2 ½ years, 3 years, and then annually through the age of 21 years.
 
*Note: Well-child visits include, but are not limited to services for developmental surveillance, psychosocial and behavioral assessments, depression and maternal depression screening, measurements, vital signs, risk assessment for Hepatitis B virus, and physical examination.
 
The appropriate ICD 10 codes to report these services are Z00.00, Z00.01, Z00.110, Z00.111, Z00.121, Z00.129, Z00.8, Z13.32, and Z71.89.
 
Codes that may be used to report this service include CPT 96127, 96160, 96161, 99381, 99382, 99383, 99384, 99385, 99391, 99392, 99393, 99394, 99395.
 
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 August 1, 2023 – December 31, 2023
 
Well-child visits are covered for members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance, or co-pay) at the following intervals: Birth, first week after birth, at age 1 month, 2 months, 4 months, 6 months, 9 months, 1 year, 15 months, 18 months, 2 years, 2 ½ years, 3 years, and then annually through the age of 21 years.
 
*Note: Well-child visits include, but are not limited to services for developmental surveillance, psychosocial and behavioral assessments, depression and maternal depression screening, measurements, vital signs, and physical examination.
 
The appropriate ICD 10 codes to report these services are Z00.00, Z00.01, Z00.110, Z00.111, Z00.121, Z00.129, Z00.8, Z13.32, and Z71.89.
 
Codes that may be used to report this service include CPT 96127, 96160, 96161, 99381, 99382, 99383, 99384, 99385, 99391, 99392, 99393, 99394, 99395.
 
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 June 2021 – July 2023
Well-child visits are covered for members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance, or co-pay) at the following intervals: Birth, first week after birth, at age 1 month, 2 months, 4 months, 6 months, 9 months, 1 year, 15 months, 18 months, 2 years, 2 ½ years, 3 years, and then annually through the age of 21 years.
 
*Note: Well-child visits include, but are not limited to services for developmental surveillance, psychosocial and behavioral assessments, depression and maternal depression screening, measurements, vital signs, and physical examination.
 
The appropriate ICD 10 codes to report these services are Z00.121, Z00.129, Z00.110, Z00.111, Z71.89, Z00.00-Z00.01 and Z00.8.
 
Codes that may be used to report this service include CPT 99381, 99382, 99383, 99384, 99385, 99391, 99392, 99393, 99394, 99395.   
 
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 2021
Well-child visits are covered for members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance or co-pay) at the following intervals: Birth, first week after birth, at age 1 month, 2 months, 4 months, 6 months, 9 months, 1 year, 15 months, 18 months, 2 years, 2 ½ years, annually until age 10 years and once between 11-14 years, 15-17 years and 18-21 years.
 
 
*Note: Well-child visits include, but are not limited to services for developmental surveillance, psychosocial and behavioral assessments, depression and maternal depression screening, measurements, vital signs and physical examination.
 
The appropriate ICD-9 code to report these services is V70.0, V20.2, V20.31 or V20.32 or V65.43, V65.49 or V70.9.
 
The appropriate ICD 10 codes to report these services are Z00.121, Z00.129, Z00.110, Z00.111, Z71.89, Z00.00-Z00.01 and Z00.8.
 
Codes that may be used to report this service include CPT 99381, 99382, 99383, 99384, 99385, 99391, 99392, 99393, 99394, 99395.   
 
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:
2021 Update
Bright Futures recommends well child visits at birth, first week after birth, at age 1 month, 2 months, 4 months, 6 months, 9 months, 1 year, 15 months, 18 months, 2 years, 2½ years, 3 years and then annually through the age of 21 years.
 
2023 Update
Assessing risk for Hepatitis B virus (HBV) infection has been added to the Bright Futures Preventive Care/Periodicity Schedule to occur from newborn to 21 years (AAP, 2022).
CPT/HCPCS:
96127Brief emotional/behavioral assessment (eg, depression inventory, attention deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument
96160Administration of patient focused health risk assessment instrument (eg, health hazard appraisal) with scoring and documentation, per standardized instrument
96161Administration of caregiver focused health risk assessment instrument (eg, depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument
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
99391Periodic 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)
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
References: American Academy of Pediatrics (AAP).(2022) Preventive Care/Periodicity Schedule. Updated 10/27/2022. https://www.aap.org/periodicityschedule. Accessed September 6, 2023.

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.
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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