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Preventive Care Services Guidelines Updated

July 10, 2012

We have updated our Preventive Care Services Coverage Determination Guideline (CDG) to help physicians identify and correctly code preventive services they deliver to members. The matrix in our CDG reflects additional codes in the expanded women’s preventive care services effective the first plan year beginning on or after Aug. 1, 2012.

Under the health reform law, non-grandfathered health plans are required to cover the expanded list of women’s preventive care services without cost-sharing (copayment, coinsurance or a deductible) as long as these services are provided by  network physicians. The CDG defines the services, diagnoses, age, gender, and other requirements for ensuring that specific services are paid with preventive benefits. While the CDG is available today, the codes added for expanded women’s preventive care services are not effective until the member’s plan renews on or after Aug. 1, 2012. 

Women’s Preventive Care Services Updates to the CDG
The list of expanded women’s preventive care services in the updated CDG are: breast-feeding support, supplies and counseling, contraceptive methods and counseling, domestic violence screening and counseling, gestational diabetes screening, human Immunodeficiency virus (HIV) screening and counseling, human papillomavirus (HPV) DNA testing, sexually transmitted infections counseling, and well-woman visits (that include preconception counseling and routine prenatal  visits.) 

New color coding helps identify specific sections of the CDG. The expanded women’s preventive care services code section appears in a red-colored table, the existing preventive codes are in a blue-colored table, and revisions are summarized in a gray-colored History section in the final pages. 

Additional Updates to the CDG
In addition to the expanded women’s preventive care benefits, other updates have been made to the Preventive Care Services CDG. The CDG is updated when new guidance is received about services that should be covered as preventive services and whenever the applicable codes are revised. (The last CDG was released in April 2012.) The U.S. Preventive Services Task Force (USPSTF) is one of the primary references driving changes to the CDG. Items that have an ‘A’ or ‘B’ rating must be covered without cost-share by non-grandfathered plans.

Other significant CDG updates include: 

  • Behavioral Counseling to Prevent Skin Cancer –– USPSTF Rating:  “B:” The USPSTF recommends counseling children, adolescents, and young adults age 10 to 24 years who have fair skin about minimizing their exposure to ultraviolet radiation to reduce risk for skin cancer. This service is provided as part of an age-appropriate preventive  examination which is already included in our preventive care coding matrix. UnitedHealthcare will not reimburse separately  for behavioral counseling to prevent skin cancer. 
  • Prostate Cancer Screening ––  USPSTF Rating: changed from” I” to “D:”At the time Patient Protection and Affordable Care Act (PPACA) was implemented, the USPSTF concluded that the current evidence was insufficient to assess the balance of benefits and harms of prostate cancer screening in men younger than age 75 years (USPSTF rating of “I”). However, UnitedHealthcare included it as part of our preventive care coding matrix.  In May 2012, the USPSTF recommended against PSA-based screening for prostate cancer (USPSTF rating of “D”). As of today, we have not changed our position, and there is no impact to the coding. 
  • Addition of the V70.0 code –– Effective for all plans with Aug. 1, 2012, dates of service and going forward (not at renewal). UnitedHealthcare is enhancing its coding matrix to allow diagnosis code V70.0 for certain services.  Those services include: Chlamydia Infection Screening; Gonorrhea Screening; HIV Screening; Syphilis Screening; Diabetes Screening; Rubella Screening; Cervical Cancer Screening, Pap Smear; Cholesterol Screening; Colorectal Cancer Screening; Osteoporosis Screening; Prostate Cancer Screening. Code V70.0 will also be allowed for HPV DNA Testing for women. Note: Using the V70.0 code may not be the only requirement for preventive benefits to be applied.  For example, Diabetes Screening with V70.0 also requires a hypertension diagnosis code from the Preventive Care Services CDG (see the CDGfor details).

Coding Summary Also Available
In addition to the full 34-page CDG, we created a three-page coding summary  to serve as a handy reference guide. The coding summary may be used by anyone, but it was created particularly to assist physicians and health care professionals.

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