BCBSNC Preventive Services Coding Guide: Understanding Healthcare Reform Compliance

Preventive care services are a cornerstone of maintaining good health, and understanding the nuances of insurance coverage for these services is crucial. For Blue Cross and Blue Shield of North Carolina (BCBSNC) members, navigating healthcare reform, particularly the Affordable Care Act (ACA), and its impact on preventive service coverage is essential. This guide provides a comprehensive overview of BCBSNC’s policies on preventive care services, with a focus on coding and compliance.

Understanding BCBSNC’s Preventive Care Policy

BCBSNC, like other insurers, is governed by the regulations set forth by the Affordable Care Act regarding preventive services. For non-grandfathered plans, which are plans created or changed significantly after the ACA was enacted, there are specific requirements for covering preventive services.

Key Categories of Preventive Services

The ACA mandates coverage without cost-sharing for a range of “Recommended Preventive Services” when delivered by an in-network provider. These services fall into several key categories:

• Evidence-based services with “A” or “B” ratings from the USPSTF: The United States Preventive Services Task Force (USPSTF) assigns ratings to preventive services based on the strength of evidence supporting their effectiveness. Services with an “A” or “B” rating, indicating substantial benefit, must be covered. This includes a wide array of screenings and counseling services aimed at preventing disease or detecting it early.

• Immunizations recommended by the ACIP: Vaccinations are a critical component of preventive care. The Advisory Committee on Immunization Practices (ACIP) at the Centers for Disease Control and Prevention (CDC) sets the standard for recommended immunizations for children, adolescents, and adults. BCBSNC plans must cover these recommended vaccines.

• Preventive care for children based on HRSA guidelines: The Health Resources and Services Administration (HRSA) supports guidelines for children’s preventive care, drawing from resources like the Bright Futures Recommendations and the Uniform Panel of the Secretary’s Advisory Committee on Heritable Disorders in Newborns and Children. These guidelines encompass regular check-ups, screenings for developmental milestones, and interventions to promote healthy development.

• Preventive care for women based on HRSA guidelines: HRSA also supports specific preventive care and screening guidelines for women, initially informed by recommendations from the Institute of Medicine. These guidelines cover a range of services unique to women’s health, including screenings for breast and cervical cancer, prenatal care, and well-woman visits.

It’s crucial to remember that for these “Recommended Preventive Services,” BCBSNC plans are required to provide coverage without any cost-sharing, meaning no co-pays, co-insurance, or deductibles when received from an in-network provider.

In-Network vs. Out-of-Network Coverage

The ACA’s preventive services mandate specifically applies to services delivered by in-network providers. BCBSNC is not required to waive cost-sharing for preventive services obtained from out-of-network providers. Therefore, to ensure full coverage without out-of-pocket expenses for these services, members should always seek care from providers within the BCBSNC network.

Cost-Sharing Details

While “Recommended Preventive Services” are covered without cost-sharing, it’s important to understand how this applies in the context of office visits. The rules are designed to ensure that the preventive service itself is free, even if it’s part of a broader office visit.

• Separately Billed Preventive Service: If a preventive service is billed separately from an office visit, cost-sharing may apply to the office visit itself, but not to the preventive service.

• Preventive Service Not Separately Billed, Primary Purpose is Preventive: If the preventive service is not billed separately, and the primary reason for the office visit is to receive the recommended preventive service, then cost-sharing cannot be applied to either the office visit or the preventive service.

• Preventive Service Not Separately Billed, Primary Purpose is Not Preventive: If the preventive service is not billed separately, but the main reason for the visit is something other than the preventive service (e.g., to address a health concern), then cost-sharing can be applied to the office visit, but still not to the preventive service itself.

These rules are in place to remove financial barriers to accessing essential preventive care while acknowledging that office visits can sometimes encompass both preventive and non-preventive services.

The Affordable Care Act and Preventive Services

The Patient Protection and Affordable Care Act (ACA) of 2010 fundamentally reshaped the landscape of healthcare in the United States. A key component of this reform was the emphasis on preventive care.

ACA Mandates for Preventive Care

The ACA aimed to shift the healthcare system towards prevention and early detection, recognizing that preventive services can improve health outcomes and reduce long-term healthcare costs. To achieve this, the ACA mandated that non-grandfathered health plans must cover “preventive care” without cost-sharing. This mandate applies to most employer-sponsored plans and individual health insurance policies.

The law defined “preventive care services” by referencing the expert recommendations from bodies like the USPSTF, ACIP, and HRSA, ensuring that the services covered are evidence-based and widely recognized as effective.

Grandfathered vs. Non-Grandfathered Plans

A crucial distinction under the ACA is between “grandfathered” and “non-grandfathered” health plans. Grandfathered plans are those that existed before the ACA was enacted and haven’t made significant changes that would cause them to lose this status. Non-grandfathered plans, which are the focus of this policy, are subject to the ACA’s preventive services mandates.

Grandfathered plans are not required to comply with the preventive services coverage requirements. However, it’s important to note that making certain changes to a grandfathered plan can cause it to lose its grandfathered status and become subject to these requirements. Changes that can revoke grandfathered status include significant benefit reductions, increased cost-sharing, or reduced employer contributions.

Compliance Deadlines

The ACA established timelines for when these preventive service coverage mandates took effect. For “Recommended Preventive Services” issued before September 23, 2009, plans were required to provide coverage starting on or after September 23, 2010. For recommendations issued after this date, coverage must be in place within one year of the recommendation’s issuance date. This ensures that as new preventive services are recommended, they are incorporated into coverage in a timely manner.

Coding and Billing for Preventive Services

Accurate coding is essential for the proper processing of claims for preventive services and ensuring that members receive the benefits they are entitled to under the ACA.

CPT Codes and Modifier 33

To facilitate accurate claims processing, specific coding guidelines are in place for ACA preventive services. Healthcare providers use Current Procedural Terminology (CPT) codes to bill for medical services. For preventive services, Modifier 33 is a key tool.

Modifier 33, “Preventive Service,” is appended to a CPT code when the primary purpose of the service is the delivery of an evidence-based preventive service that meets ACA criteria (USPSTF “A” or “B” rating or other mandated preventive services). Using Modifier 33 signals to the insurer, like BCBSNC, that the service should be processed as a preventive service and therefore be covered without cost-sharing for in-network providers in non-grandfathered plans.

It’s important to note that correct coding also requires the appropriate ICD-10 diagnosis codes to further specify the reason for the encounter and support the preventive nature of the service. Refer to BCBSNC’s specific “Healthcare Reform Preventive Care Services Coding document” for the most up-to-date and detailed coding requirements.

Documentation Requirements

Clear and comprehensive medical record documentation is crucial. The patient’s medical record must clearly document the nature of the preventive service provided. This documentation supports the coding and billing process and ensures accurate claims processing and compliance with ACA regulations.

Conclusion

Understanding BCBSNC’s preventive services coding guide and the broader context of healthcare reform is vital for both healthcare providers and BCBSNC members. By adhering to these guidelines, providers can ensure accurate billing and coding, and patients can confidently access the preventive care services they need without unexpected cost-sharing. This ultimately contributes to improved health outcomes and a more proactive approach to healthcare management. For the most precise and current coding details, always refer to the official BCBSNC “Healthcare Reform Preventive Care Services Coding document.”

References:

1. American Academy of Pediatrics. Bright Futures: Coding for Pediatric Preventive Care Booklet, 2022. www.downloads.aap.org/AAP/PDF/Coding%20Preventive%20Care.pdf
2. American Academy of Pediatrics/Bright Futures. Recommendations for Preventive Pediatric Health Care. American Academy of Pediatrics. www.aap.org/en/practice-management/care-delivery-approaches/periodicity-schedule/
3. Advisory Committee on Heritable Disorders in Newborns and Children. Recommended Uniform Screening Panel. www.hrsa.gov/advisory-committees/heritable-disorders/rusp/index.html
4. Advisory Committee on Immunization Practices (ACIP) Recommendations. www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/index.html
5. Centers for Disease Control (CDC). Immunization Schedules. Vaccines and Immunizations, www.cdc.gov/vaccines/recs/schedules/default.htm.
6. Healthcare.gov. Preventive care benefits for adults. www.healthcare.gov/preventive-care-adults/
7. Healthcare.gov. Preventive care benefits for children. www.healthcare.gov/preventive-care-children/
8. Healthcare.gov. Preventive care benefits for women. www.healthcare.gov/preventive-care-women/
9. Institute of Medicine. Clinical Preventive Services for Women-Closing the Gaps. 2011. www.nap.edu/read/13181/chapter/1#iii
10. National Archives and Records Administration. Group Health Plans and Health Insurance Coverage Relating to Status as a Grandfathered Health Plan under the Patient Protection and Affordable Care Act; Interim Final Rule and Proposed Rule. Federal Register, June 17, 2010, Part II, Department of the Treasury, Internal Revenue Service 26 CFT Parts 54 and 602; Department of Labor, Employee Benefits Security Administration, 29 CFR Part 2590; Department of Health and Human Services, 45 CFT Part 147.
11. U.S. Preventive Services Task Force (USPSTF). Recommendations. www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics
12. Women’s Preventive Services Guidelines (HRSA). www.hrsa.gov/womens-guidelines
13. Women’s Preventive Services Initiative (WPSI). www.womenspreventivehealth.org/recommendations