The Affordable Care Act (ACA) has provisions that ensure patients can receive certain preventive services without any out-of-pocket expenses. This means when healthcare providers order specific evidence-based preventive care for their patients, insurance companies are expected to cover the full cost, leaving patients with zero cost-sharing. Understanding and accurately applying the correct coding for these services is crucial in 2024 to guarantee patients benefit from this ACA provision.
Understanding ACA Zero-Dollar Preventive Services
The ACA mandates that most private health insurance plans must provide zero-dollar coverage for preventive services recommended by four designated organizations. These organizations set the standards for evidence-based preventive care. Coverage is directly linked to these recommendations. Therefore, it’s vital for healthcare providers to know which patient groups are eligible for specific preventive services without cost-sharing and when cost-sharing might apply for the same services. Precise coding is essential to correctly identify and bill for qualifying preventive services.
AMA Guides for Accurate Preventive Service Coding
The American Medical Association (AMA) offers valuable resources to help practices bill accurately for zero-dollar preventive services. These guides are designed to navigate the complexities of coding and ensure proper reimbursement while eliminating patient cost-sharing.
Preventive Services Coding Guide Finder
The AMA provides a dedicated online tool that allows users to search for preventive services that qualify for zero patient cost-sharing. You can search by keyword, CPT code, or HCPCS code to quickly find the necessary coding information.
How Healthcare Providers Facilitate Patient Benefits
Clear communication to payers through meticulous documentation and coding is paramount. When physicians and other healthcare providers accurately code and document healthcare services, they inform insurance plans of their responsibility to cover the patient’s bill fully. Without proper coding, insurance plans may not recognize the service as a fully covered preventive service, potentially leading to surprise bills for patients.
Coding Rules for ACA Zero-Dollar Preventive Services: Commercial Payers
Confusion and inconsistencies in coding and claims processing for preventive services persist among payers, physicians, and healthcare providers. To streamline billing for commercial payers, the AMA recommends the following coding guidance.
Modifier 33, from the Current Procedural Terminology (CPT) code set, is specifically designed for billing ACA-designated preventive services to commercial payers. Adding modifier 33 signals to the commercial payer that the service was provided as an ACA preventive service. This modifier is useful not only for ACA preventive services but also in situations where a screening procedure, like a colonoscopy, becomes diagnostic or therapeutic.
Alt text: Preventive services coding tools guide physicians in accurate billing for ACA-mandated no-cost patient care in 2024.
Modifier 33 should be applied when the primary aim of the service aligns with evidence-based guidelines from ACA-designated organizations, including services with an A or B recommendation from the USPSTF (U.S. Preventive Services Task Force).
If modifier 33 is not used, the insurance plan might incorrectly assume the preventive service was for a patient ineligible for the zero-dollar benefit, and the patient could be wrongly billed. Patient eligibility for the zero-dollar benefit hinges on meeting the evidence-based recommendations set by the four ACA designated organizations.
Here are steps to ensure your patients receive zero-dollar preventive services:
Step 1
Refer to the guidelines from the four ACA designated organizations for the most current lists of recommended preventive services that are available without patient cost-sharing for eligible populations. It’s important to note that services recommended by any of these organizations must be covered without cost-sharing within one year of the recommendation date.
Step 2
Use the correct CPT code(s) for the service provided and always append modifier 33 to indicate that it is an ACA-designated preventive service.
Step 3
For any questions about CPT coding, the AMA’s CPT Network is a valuable resource for AMA members and CPT Network subscribers.
Private Payer Coding Guide
The AMA offers a downloadable guide specifically for private payer coding of preventive services that should not incur patient cost-sharing.
Access Now (PDF)
Examples of Preventive Services and Coding
Here are some examples to clarify eligible and ineligible scenarios for zero-dollar preventive benefits:
Preventive service: Biennial screening mammography
- Eligible for zero-dollar benefit: Women aged 50 to 74 with an average risk of breast cancer.*
- Not eligible for zero-dollar benefit: Women younger or older, or those with specific breast cancer risk factors.
*While USPSTF recommends screening from age 50, legislation allows no cost-sharing screening starting at age 40.
Preventive service: Colorectal cancer screening
- Eligible for zero-dollar benefit: Asymptomatic adults aged 50 to 75 at average risk.
- Not eligible for zero-dollar benefit: Younger or older adults, or those with symptoms or specific risk factors for colorectal cancer.
Preventive service: Chlamydia and gonorrhea screening
- Eligible for zero-dollar benefit: Sexually active women aged 24 and younger, and older women at increased risk of infection.
- Not eligible for zero-dollar benefit: Women over 24 not at increased risk, and all men.
Preventive service: One-time abdominal aortic aneurysm (AAA) screening with ultrasonography
- Eligible for zero-dollar benefit: Men aged 65 to 75 who have ever smoked.
- Not eligible for zero-dollar benefit: Men who have never smoked, and all women.
Coding Rules for ACA Zero-Dollar Preventive Services: Medicare
Medicare initially had a slower uptake of CPT modifier 33 after its introduction in 2010. However, Medicare Administrative Contractors (MACs) have since provided further guidance on its use. For example, in 2015, Medicare permitted modifier 33 for anesthesia during screening colonoscopies. In 2016, Medicare mandated modifier 33 for Advance Care Planning services when provided with Annual Wellness Visits, ensuring waived coinsurance and deductibles.
It’s important to note that some preventive services covered by Medicare do not have a USPSTF grade A or B recommendation. These include:
- Digital rectal exams for prostate screening.
- Glaucoma screening.
- DSMT services.
- Barium enemas for colorectal cancer screening (where the deductible is waived through separate statute provisions).
Modifier 33 is not applicable in these cases.
Medicare uses modifier PT to indicate when a service initially intended as a colorectal cancer screening becomes diagnostic due to findings. Modifier PT is then appended to the diagnostic procedure code instead of the screening code.
Practices should always consult their local MACs for specific rules on reporting preventive services under Medicare and refer to the Medicare Preventive Services website for detailed information.
Medicare Coding Guide
The AMA also provides a specific guide for Medicare coding of preventive services that should be provided to patients without cost-sharing.
Access Now (PDF)
Disclaimer: The information provided by the AMA is for guidance and does not constitute clinical advice, dictate payer reimbursement policies, or substitute professional judgment in coding. Practitioners are responsible for accurate coding.
