Date Issued: 1/12/2018
The Affordable Care Act (ACA) requires non-grandfathered health plans in the individual and group markets to cover certain preventive/screening care services received from in-network providers, in full, without member cost-sharing (i.e., without co-pay, deductible and/or co-insurance). In general, eligible services include preventive/screening care services which have received an “A” or “B” rating from the United States Preventive Services Task Force (USPSTF) or have been set forth in comprehensive guidelines supported by the Health Resources and Services Administration (HRSA), as well as immunizations recommended by the Advisory Committee on Immunization Practices (ACIP). For additional information about these guidelines and recommendation, please click on the link(s) below:
https://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/
https://bphc.hrsa.gov/policiesregulations/preventiveguide.html
https://www.cdc.gov/vaccines/acip/
Effective 1/1/2018
Updated Instructions for Anesthesia for Colon Cancer Screenings to Providers for Coding Claims for ACA Mandated Preventive Care Services:
Preventive/Screening Colonoscopy
- Services provided by the in-network endoscopist, anesthesiologist and pathologist associated with an in-network preventive/screening colonoscopy are eligible for coverage without member cost-sharing.
- With the understanding that a preventive/screening colonoscopy may become diagnostic or therapeutic due to unforeseen findings, the AMA CPT Code that most accurately represents the procedure performed should be reported. The appropriate preventive/screening ICD diagnosis code (e.g., V76.51) should be entered into the first claim diagnosis field.
- Anesthesia services should be reported with any specific findings entered into the first claim diagnosis field. The second claim diagnosis code should be reported with the appropriate preventive/screening ICD diagnosis code (e.g., Z12.11). CPT code 00812 MUST be used if the screening colonoscopy becomes a diagnostic colonoscopy and/or if the screening colonoscopy is stopped due to poor preparation and a sigmoidoscopy is done. While modifier 33 may be reported along with the anesthesia CPT code, it is not used in making preventive care benefit determinations; EmblemHealth considers the procedure and diagnosis codes when determining whether preventive care benefits apply. Pathology services should be reported with the appropriate screening ICD diagnosis code (e.g., Z12.11) entered into the first claim diagnosis field. Pathology services should be reported with the appropriate screening ICD diagnosis code (e.g., V76.51) entered into the first claim diagnosis field.
Additionally, the American Medical Association (AMA) has published coding changes effective 0101/2018. Please note the following additions and deletions to the Preventive Care Services Table:
Deleted CPT/HCPCS codes as of 12/31/2017:
Q2039 - Influenza virus vaccine, not otherwise specified
G0202 - Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed
00810 - Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum
New CPT/HCPCS codes effective 01/01/2018:
90756 - Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, antibiotic free, 0.5 mL dosage, for intramuscular use
00812 - Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; screening colonoscopy
G0513 - Prolonged preventive service(s) (beyond the typical service time of the primary procedure), in the office or other outpatient setting requiring direct patient contact beyond the usual service; first 30 minutes (list separately in addition to code for preventive service)
G0514 - Prolonged preventive service(s) (beyond the typical service time of the primary procedure), in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes (list separately in addition to code g0513 for additional 30 minutes of preventive service)
0500T - Infectious agent detection by nucleic acid (DNA or RNA), human papillomavirus (HPV) for five or more separately reported high-risk HPV types (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) (ie, genotyping)
J7296 - Levonorgestrel-releasing intrauterine contraceptive system, (kyleena), 19.5 mg
Please refer to the EmblemHealth Preventive Care/Screening Services Table.
