Preventive Services for Non-Grandfathered (PPACA) Plans: Behavioral Counseling for Prevention - CAM 086

Description:
The federal Patient Protection and Affordable Care Act (PPACA) was passed by Congress and signed into law by the president in March 2010. The preventive services component of the law became effective Sept. 23, 2010. A component of the law was a requirement that all “non-grandfathered” health insurance plans are required to cover preventive medicine services given an “A” or “B” recommendation by the U.S. Preventive Services Task Force (USPSTF) and preventive services recommended by the Health Resources and Services Administration (HSRA).

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, coinsurance or copay) 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, coinsurance or copay may be applied.

Policy:
Behavioral counseling regarding the promotion of health and preventing illness or injury is considered MEDICALLY NECESSARY according to the U.S. Preventive Services Task Force for non-grandfathered PPACA plan members. A review of risk factors is appropriate once yearly.

Rationale:
Preventive Coverage
Preventive Medicine, Individual Counseling
CPT codes 99401 – 99404 are designated to report services provided to individuals at a face-to-face encounter for the purpose of promoting health and preventing illness or injury.

Preventive medicine counseling and risk factor reduction interventions will vary with age and should address issues including:

- Diet and exercise (such as related to obesity, hyperlipidemia).
- Substance misuse/abuse.
- Sexual practices and STD/STI prevention.
- Screening procedures and laboratory test results available at the time of the encounter.
- Breast-feeding counseling and support.
- Domestic and interpersonal violence.
- FDA-approved contraception methods for women with reproductive capacity.

Risk factor reduction services are used for persons without a specific illness for which the counseling might otherwise be used as part of treatment.

These codes are not to be used to report counseling and risk factor reduction interventions provided to patients with symptoms or established illness.

For counseling individual patients with symptoms or established illness, use the appropriate office, hospital, consultation or other evaluation and management codes.

Codes 99402 – 99404 will require record review.

Coding description:

99401 PREVENTIVE MEDICINE COUNSELING AND/OR RISK FACTOR REDUCTION INTERVENTION(S) PROVIDED TO AN INDIVIDUAL (SEPARATE PROCEDURE); APPROXIMATELY 15 MINUTES

99402 PREVENTIVE MEDICINE COUNSELING AND/OR RISK FACTOR REDUCTION INTERVENTION(S) PROVIDED TO AN INDIVIDUAL (SEPARATE PROCEDURE); APPROXIMATELY 30 MINUTES

99403 PREVENTIVE MEDICINE COUNSELING AND/OR RISK FACTOR REDUCTION INTERVENTION(S) PROVIDED TO AN INDIVIDUAL (SEPARATE PROCEDURE); APPROXIMATELY 45 MINUTES

99404 PREVENTIVE MEDICINE COUNSELING AND/OR RISK FACTOR REDUCTION INTERVENTION(S) PROVIDED TO AN INDIVIDUAL (SEPARATE PROCEDURE); APPROXIMATELY 60 MINUTES

References:

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

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

History From 2014 Forward

04/10/2024	Annual review, no change to policy intent.
04/05/2023	Adding the following bullets to the list of preventative medicine counseling topics: Breast-feeding counseling and support Domestic and interpersonal violence FDA-approved contraception methods for women with reproductive capacity. No other changes.
04/01/2022	Annual review, no change to policy intent.
04/01/2021	Annual review, no change to policy intent.
04/08/2020	Annual review, no change to policy intent or USPSTF guidance.
04/01/2019	Annual review, no change to policy intent or USPSTF guidelines regarding these services.
03/26/2018	Annual review, removing tobacco use and cessation from this policy as this is addressed in CAM 089 with CPT coding specific to that counseling. No other changes made to policy.
04/19/2017	Annual review. There have been no changes to the USPSTF guidelines.
04/06/2016	Annual review, no change to policy intent.
04/07/2015	Annual review, no changes made.
03/25/2014	New Policy

Policy List

Edit Policy

{{ navigationConstituentPage.title || { 'medicalpolicyhb': 'Healthy Blue Medical Policies', 'medicalpolicyih': 'InStil Health Medical Policies' }[navigationSitePage.urlName] || 'Medical Policies' }}

Preventive Services for Non-Grandfathered (PPACA) Plans: Behavioral Counseling for Prevention - CAM 086