The requirement that health plans cover select preventive services without zero-dollar patient cost-sharing has been one of the most popular features of the Affordable Care Act (ACA). In practice, however, physicians have run into a number of hang-ups in providing that preventive care without triggering copays or deductibles for their patients. Two new preventive services coding guides from the AMA eliminate the guesswork.

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The guides, one for Medicare and another for private payers, are available for free on the AMA website. Each provides an alphabetical list of covered evidence-based preventive services—including screenings and vaccinations, as well as counseling and other interventions—along with details of the relevant at-risk populations and the pertinent billing codes.

The private payer guide, for example, details more than 90 services, each with patient population recommendations from the Advisory Committee on Immunization Practices (ACIP), Bright Futures, the U.S. Preventive Services Task Force (USPSTF) or the Women’s Preventive Services Initiative. Alongside those are all the respective Current Procedural Terminology (CPT®) codes.

The Medicare guide breaks out nearly 30 preventive services, each showing eligible Medicare beneficiaries and the respective CPT and Healthcare Common Procedure Coding System (HCPCS) codes, as well as indications of whether copays, coinsurance and deductibles are waived.

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The guides were developed per recommendations in a joint report from the AMA Council on Medical Service and the AMA Council on Science and Public Health, which cited persistent confusion among patients, physicians and payers in paying for preventive services.

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Patients often “are not familiar with the preventive services that are available to them without cost-sharing,” the 2018 report said. “Three and half years after the ACA took effect, less than half the population (43%) reported being aware that the ACA eliminated out-of-pocket expenses for preventive services.”

As a case in point, private insurers may still impose cost-sharing if a physician bills the visit separately from the preventive service or if the service wasn’t the primary purpose for the visit; sometimes it isn’t even clear who determines the visit’s primary purpose.

Patient cost-sharing has “been shown to cause people, especially those in low-income and vulnerable populations, to forgo not only unnecessary but also necessary care,” the report said. “In fact, as little as a $10 rise in co-payments has been associated with a significant decline in outpatient visits and a concurrent increase in hospital utilization among an elderly population.”

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An AMA webpage about the guides emphasizes the importance of including CPT modifier 33 when billing for ACA-designated preventive services with a commercial payer, noting that it should be used when the primary purpose of the service was delivery of an evidence-based service in accordance with the guidelines provided by one of the aforementioned ACA-designated organizations.

“If physicians and other health care providers do not specify modifier 33, the insurance plan may think that the preventive service was for a patient who is not eligible for the zero-dollar benefit, and the patient may be billed,” it says.

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The webpage also gives specific examples of preventive recommendations from the USPSTF for non-symptomatic patients—including which patients are eligible for a zero-dollar benefit—and outlines the use of modifiers when coding for patients covered by Medicare.

The AMA is closely monitoring the COVID-19 pandemic. Learn more at the AMA COVID-19 resource center. Also check out pandemic resources available from the AMA Code of Medical Ethics, JAMA Network™ and AMA Journal of Ethics, and consult the AMA’s physician guide to COVID-19.

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