Abdominal Aortic Aneurysm (AAA) Screening

[Pages:3]Benefit Payment Guideline

Abdominal Aortic Aneurysm (AAA) Screening

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Benefit Policy Statement:

Some preventive and wellness services rendered by a participating provider are exempt from member cost share under the Federal Patient Protection and Affordable Care Act (PPACA). These services are defined by the United States Preventive Service Task Force Grade A&B and those services recommended by the Health Resource and Services Administration. The Provider must code the service as a preventive service.

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Benefit Policy Guidelines:

The U.S Preventive Services task Force (USPSTF) recommends one-time screening for abdominal aortic aneurysm (AAA) by ultrasonography in men aged 65 to 75 who have ever smoked (Grade B).

The Plan will not require the Member to pay: A coinsurance, copayment, deductible or other out-of-pocket expense when preventive services are received by an in-network provider and coded by the provider as a preventive service.

The Plan will require the Member to pay: A coinsurance, copayment, deductible or other out-of-pocket expense when preventive services are rendered by an out-of?network provider Any non-preventive services received in conjunction with a preventive service visit.

LOB:

Commercial ? On exchange and off exchange Large group Small group Individual

Procedure/Services: The procedure/services will be payable as preventive with the following codes listed

within the recommended preventive services interval.

Proprietary and Confidential Benefit Payment Guidelines are developed by HealthyCT to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Guideline may contain only a partial, general description of plan or program benefits and does not constitute a contract. This Guideline may be updated and therefore is subject to change.

Screening for Abdominal Aortic Aneurysm (AAA): Approved at 7/11/14 PCP committee meeting

CPT/HCPCS CODES 76700 76705

76770 76775 G0389

DESCRIPTION OF CODE Ultrasound, abdominal, real time with image documentation; complete Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, followup) Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; complete Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; limited Ultrasound B-scan and/or real time with image documentation; for abdominal aortic aneurysm (AAA) screening

COMMENTS

One time screening for men ages 65-75 who have ever smoked.

Covered as preventive when billed with:

Before 10/01/2015: ICD.9 V-code V15.82

On or after 10/01/2015: ICD.10 code Z87.891

ICD-9

DESCRIPTION OF CODE

V15.82

Personal history of tobacco use,

presenting hazards to health

For Services On or After 10/01/2015:

ICD.10

DESCRIPTION OF CODE

Z87.891

Personal history of nicotine

dependence

COMMENTS Once per lifetime

COMMENTS Once per lifetime

Diagnostic Services: A claim for diagnostic services will be processed under the applicable diagnostic benefit with the applicable member cost share. Examples include:

1. Had abnormalities found on previous preventive or diagnostic procedures that require further diagnostic studies.

2. Had abnormalities found on previous preventive or diagnostic procedures that would recommend a repeat of the same procedures within shortened time intervals from the recommended preventive services intervals.

3. Had a symptom(s) that required further diagnosis.

Proprietary and Confidential Benefit Payment Guidelines are developed by HealthyCT to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Guideline may contain only a partial, general description of plan or program benefits and does not constitute a contract. This Guideline may be updated and therefore is subject to change.

Screening for Abdominal Aortic Aneurysm (AAA): Approved at 7/11/14 PCP committee meeting

Examples of Claim Adjudication Scenarios: Preventive vs. Diagnostic:

1. Member is a 65 year old male with previous history of smoking and is scheduled for an abdominal aortic aneurysm (AAA) by ultrasonography. Provider bills CPT code 76770 with and ICD.10 code Z87.891. This would be considered a preventive service with no cost to the member.

2. Member is a 60 year old male with no previous history of smoking but with abdominal symptoms requiring an abdominal ultrasound. Provider bills CPT code 76775 and ICD.10 code R10.9 or R10.0. The procedure code billed is used for preventive services but the ICD.10 code is not and therefore based on the age of the member (or insured) and the diagnosis code, this would be considered a diagnostic procedure and subject to the member's benefit plan.

3. Member is a 73 year old male with previous history of smoking and is scheduled for an abdominal aortic aneurysm (AAA) by ultrasonography. Provider bills CPT code 76770 with and ICD.10 code Z87.891. Member or insured, also scheduled for an ultrasound of the carotid arteries. Provider bills CPT code 93880 and ICD.10 code R55. No cost share would be taken on CPT code 76770 as this is considered a preventive service within the recommended preventive service criteria but cost share would be taken on CPT code 93880 as this is a non-preventive service.

Exclusions/Limitations

A coinsurance, copayment and deductible will be applied according to the member's benefit plan when preventive services are rendered by an out-of?network provider

References

1 Screening for Abdominal Aortic Aneurysm, Topic Page. U.S. Preventive Services Task Force. Member's COC

Document History

7/11/2014 07/24/2015

Initial Version

Annual Review: CPT Codes 76700 & 76705 and ICD.10 code Z87.891 added to guideline. Replaced ICD.9 codes with ICD.10 codes in Examples of Claim Adjudication Scenarios section.

Proprietary and Confidential Benefit Payment Guidelines are developed by HealthyCT to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Guideline may contain only a partial, general description of plan or program benefits and does not constitute a contract. This Guideline may be updated and therefore is subject to change.

Screening for Abdominal Aortic Aneurysm (AAA): Approved at 7/11/14 PCP committee meeting

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