Coverage Policy Manual
Policy #: 2012047
Category: PPACA Preventive
Initiated: August 2012
Last Review: June 2023
  PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: CARDIOMETABOLIC RISKS OF OBESITY IN CHILDREN AND 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:
Effective June 2021
 
Screening for cardiometabolic risks of obesity is covered as part of the well-child visit for members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance or co-pay).
 
Note: Well-child visits are discussed in policy #2012046 and are recommended 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.
 
The appropriate ICD-10 codes to report these services are Z00.00, Z00.01, Z00.8, Z00.121 and Z00.129.
 
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
 
Screening for cardiometabolic risks of obesity is covered as part of the well-child visit for members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance or co-pay).
 
Note: Well-child visits are discussed in policy #2012046 and are recommended 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.
 
The appropriate ICD-9 code to report these services is V70.0, V70.9 or V20.2.
 
The appropriate ICD-10 codes to report these services are Z00.00, Z00.01, Z00.8, Z00.121 and Z00.129.
 
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:
Performing Preventive Services, A Bright Futures Handbook (Tanski, 2008) offers the following information regarding the cardiometabolic risk of obesity in children and adolescents:
 
An individual is said to have metabolic syndrome if he or she meets 3 or more of the following 5 criteria:
 
      • Age- and gender-specific elevated blood pressure (systolic blood pressure and/or diastolic blood pressure ≥90th percentile)
      • Elevated waist circumference
      • Elevated triglycerides
      • Low high-density lipoprotein (HDL) cholesterol
      • Elevated fasting glucose (≥100 mg/dL)
 
To determine if a child is at risk for cardiometabolic abnormalities assess for the following:
 
    • Measure Body Mass Index (BMI). Measure weight and height beginning at age 2 and calculate and plot BMI for age and gender at all health supervision visits.
    • Measure Blood Pressure at all health supervision visits beginning with the 3-year visit.
    • Screen for dyslipidemias.
    • Screen for insulin resistance and type 2 diabetes. Because insulin resistance is a key factor in this syndrome; overweight patients may need to be screened for type 2 diabetes. If fasting blood glucose is greater than 100, an oral glucose tolerance test should be performed or the fasting glucose should be repeated in 3 months.
    • Measure waist circumference. Visceral adipose tissue is fat tissue found in the intra-abdominal cavity and is an important component of excess central fat tissue because it has been shown to have different metabolic properties than subcutaneous fat. Excess visceral at is associated with increased insulin resistance and dyslipidemia related to free fatty acid turnover.
 
Abnormal values from a single point are not diagnostic for any obesity comorbidity like hypertension or hypercholesterolemia. Follow up with the patient and family on any abnormal results.
 
Weight loss is the primary target for treating cardiometabolic abnormalities of obesity. Include family members when behavioral change for weight loss is the goal.
 
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
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: 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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