Coverage Policy Manual
Policy #: 2012055
Category: PPACA Preventive
Initiated: August 2012
Last Review: July 2024
  PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: PREVENTION OF FALLS IN COMMUNITY-DWELLING OLDER ADULTS
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.  
 
Plans are not required to provide coverage for the preventive services if they are delivered by out-of-network providers.
 
Task Force recommendations are graded on a five-point scale (A-E), reflecting the strength of evidence in support of the intervention.  Grade A: There is good evidence to support the recommendation that the condition be specifically considered in a periodic health examination.  Grade B: There is fair evidence to support the recommendation that the condition be specifically considered in a periodic health examination.  Grade C: There is insufficient evidence to recommend for or against the inclusion of the condition in a periodic health examination, but recommendations may be made on other grounds.  Grade D: There is fair evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.  Grade E: There is good evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.
 
Those preventive medicine services listed as Grade A & B recommendations are covered without cost sharing (i.e., deductible, co-insurance, or co-pay).by Health Plans for appropriate preventive care services provided by an in-network provider.  If the primary purpose for the office visit is for other than Grade A or B USPSTF preventive care services, deductible, co-insurance, or copay may be applied.
 
 
Policy/
Coverage:
EFFECTIVE JULY 2018
 
Physical Therapy or exercise to prevent falls in community-dwelling adults aged 65 years or older who are at increased risk for falls is covered once per year, subject to the limitations set forth in the member benefit certificate for rehabilitative services for members of “non-grandfathered” plans without cost-sharing (i.e., deductible, co-insurance, or co-pay):
 
The appropriate ICD-10 code to report these services is Z91.81
 
The codes used to report this procedure are 97001, 97002, 97110, 97112, 97116, 97750, G0159 or S9131. 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 JULY 2018
 
Physical Therapy and Vitamin D supplementation to prevent falls in community-dwelling adults aged 65 years or older who are at increased risk for falls is covered once per year, subject to the limitations set forth in the member benefit certificate for rehabilitative services for members of “non-grandfathered” plans without cost-sharing (i.e., deductible, co-insurance, or co-pay):
The appropriate ICD-9 code to report these services is V15.88.
The appropriate ICD-10 code to report these services is Z91.81
The codes used to report this procedure are 97001, 97002, 97110, 97112, 97116, 97750, G0159 or S9131. 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.
EFFECTIVE PRIOR TO JULY 2015
Physical Therapy to prevent falls in community-dwelling adults aged 65 years or older who are at increased risk for falls is covered once per year, subject to the limitations set forth in the member benefit certificate for rehabilitative services for members of “non-grandfathered” plans without cost-sharing (i.e., deductible, co-insurance, or co-pay):
The appropriate ICD-9 code to report these services is V15.88.
The codes used to report this procedure are 97001, 97002, 97110, 97112, 97116, 97750, G0159 or S9131. 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  
Physical Therapy and Vitamin D supplementation to prevent falls in community-dwelling adults aged 65 years or older who are at increased risk for falls is covered once per year, subject to the limitations set forth in the member benefit certificate for rehabilitative services for members of “non-grandfathered” plans without cost-sharing (i.e., deductible, co-insurance, or co-pay):
 
The appropriate ICD-9 code to report these services is V15.88.
 
The appropriate ICD-10 code to report these services is Z91.81
 
The codes used to report this procedure are 97001, 97002, 97110, 97112, 97116, 97750, G0159 or S9131. 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.
 
EFFECTIVE PRIOR TO JULY 2015
Physical Therapy to prevent falls in community-dwelling adults aged 65 years or older who are at increased risk for falls is covered once per year, subject to the limitations set forth in the member benefit certificate for rehabilitative services for members of “non-grandfathered” plans without cost-sharing (i.e., deductible, co-insurance, or co-pay):
 
The appropriate ICD-9 code to report these services is V15.88.
 
The codes used to report this procedure are 97001, 97002, 97110, 97112, 97116, 97750, G0159 or S9131. 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 USPSTF recommendations include the following information (Moyer, 2012).
 
    • Falls are the leading cause of injury in adults aged 65 years or older. Between 30% and 40% of community-dwelling adults aged 65 years or older fall at least once per year.
 
    • The USPSTF found convincing evidence that exercise or physical therapy has moderate benefit in preventing falls in older adults. Adequate evidence indicates that vitamin D supplementation has moderate benefit in preventing falls in this population and that interventions identified and categorized as multifactorial risk assessment with comprehensive management of identified risks have at least a small benefit in preventing falls. Comprehensive multifactorial assessment and management interventions include assessment of multiple risk factors for falls and providing medical and social care to address factors identified during the assessment. It is possible that some combination of interventions in a select population could provide important benefits, but given the current evidence, the USPSTF is uncertain what that combination or population would be.
 
    • The USPSTF found convincing evidence that the harms of vitamin D supplementation are no greater than small. Adequate evidence indicates that the harms of physical therapy or exercise are small. These harms include a paradoxical increase in falls and an increase in physician visits.
 
    • The USPSTF found convincing evidence that the harms of multifactorial assessment with comprehensive management of identified risks are no greater than small.
 
    • This recommendation applies to interventions that are feasible in primary care for community-dwelling adults aged 65 years or older.
 
    • Primary care clinicians can reasonably consider a small number of factors to identify older persons at increased risk for falls. Age itself is strongly related to risk for falls (Michael, 2010a; Michael, 2010b). Several clinical factors, including a history of falls, a history of mobility problems, and poor performance on the timed Get-Up-and-Go test (Mathias, 1986; Podsiadlo, 1991), also identify persons at increased risk for falling. A history of falling is most commonly used to identify increased risk for future falling and has generally been considered concurrently or sequentially with other key risk factors, particularly gait and balance. A pragmatic, expert-supported approach to identifying high-risk persons uses a history of falls and mobility problems and the results of a timed Get-Up-and-Go test. The test is performed by observing the time it takes a person to rise from an armchair, walk 3 meters (10 feet), turn, walk back, and sit down again (Podsiadlo, 1991).  The average healthy adult older than 60 years can perform this task in less than 10 seconds (Bohannon, 2006). The USPSTF did not find evidence about frequency of a brief falls risk assessment, but other organizations, including the American Geriatric Society (AGS), recommend that clinicians ask their patients yearly about falls and balance or gait problems.
 
    • Effective exercise and physical therapy interventions include group classes and at-home physiotherapy strategies. Effective interventions range in intensity from low (≤9 hours) to high (>75 hours). The U.S. Department of Health and Human Services recommends that older adults get at least 150 minutes per week of moderate-intensity or 75 minutes per week of vigorous-intensity aerobic physical activity, as well as muscle-strengthening activities twice per week (DHHS, 2008). It also recommends balance training 3 or more days per week for older adults at risk for falling because of a recent fall or difficulty walking (DHHS, 2008). The AGS recommends that exercise interventions include balance, gait, and strength training.
 
    • The trials studied a wide range of doses and durations for vitamin D supplementation; the median dose was 800 IU daily and the median duration was 12 months. The data suggest that benefit from vitamin D supplementation occurs by 12 months; the efficacy of shorter treatment is unknown. According to the Institute of Medicine, the recommended daily allowance for vitamin D is 600 IU for adults aged 51 to 70 years and 800 IU for adults older than 70 years (IOM, 1997). The AGS recommends 800 IU per day for persons at increased risk for falls.
 
CPT/HCPCS:
97110Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
97112Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities
97116Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing)
97750Physical performance test or measurement (eg, musculoskeletal, functional capacity), with written report, each 15 minutes
G0159Services performed by a qualified physical therapist, in the home health setting, in the establishment or delivery of a safe and effective physical therapy maintenance program, each 15 minutes
S9131Physical therapy; in the home, per diem
References: 2008 Physical Activity Guidelines for Americans. Washington, DC: U.S. Department of Health and Human Services.(2008) U.S. Department of Health and Human Services. Accessed at www.health.gov/paguidelines/guidelines/default.aspx#toc on 24 August 2012.

Bohannon RW.(2006) Reference values for the timed up and go test: a descriptive meta-analysis. J Geriatr Phys Ther. 2006;29:64-8. [PMID: 16914068]

Mathias S, Nayak US, Isaacs B.(1986) Balance in elderly patients: the "get-up and go" test. Arch Phys Med Rehabil. 1986;67:387-9. [PMID: 3487300]

Michael YL, Lin JS, Whitlock EP, Gold R, Fu R, O'Connor EA, et al.(2010) Interventions to Prevent Falls in Older Adults: An Updated Systematic Review. Evidence Synthesis No. 80. AHRQ Publication No. 11-05150-EF1. Rockville, MD: Agency for Healthcare Research and Quality; December 2010.

Michael YL, Whitlock EP, Lin JS, Fu R, O'Connor EA, Gold R;(2010) US Preventive Services Task Force. Primary care–relevant interventions to prevent falling in older adults: a systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med. 2010;153:815-25. [PMID: 21173416]

Moyer V.A.(2012) Prevention of falls in community-dwelling older adults: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 7 August 2012;157(3):197-204.

Podsiadlo D, Richardson S.(1991) The timed "Up & Go": a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39:142-8. [PMID: 1991946]

PPACA & HECRA: Public Laws 111-148 & 111-152. The Patient Protection and Affordable Care Act

Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board, Institute of Medicine. Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. Washington, DC: National Academy Press; 1997. Accessed at www.nal.usda.gov/fnic/DRI//DRI_Calcium/calcium_full_doc.pdf on 5 April 2012.
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 © 2024 American Medical Association.