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CPT® and Affordable Care Act Create Payer Conundrum

When it comes to meeting “first dollar coverage” requirements using CPT®, the two are at odds.

By Kenneth D. Beckman, MD, MBA, CPC, CPC-P, CPC-H, CPE
The Affordable Care Act (ACA), or Obamacare, includes a list of services that payers are required to cover without a deductible or co-pay—what is commonly referred to as “first dollar coverage.” These services include preventive care for adults and children, as well as prenatal (antepartum) care for pregnant women.
These codes have worked well for many years, but do create a conundrum in coding under the ACA. Let’s take a look at the difficulty payers face when following the ACA first dollar coverage requirement using current CPT® coding.
Author’s note: This article has no political intent, and is neither an endorsement nor a criticism of the ACA. Likewise, the article is not a critique of the American Medical Association’s CPT® codebook.
Maternity Care
Under the ACA, prenatal care is a first dollar benefit. It’s not yet clear what, specifically, is included under prenatal care. But it’s certain that the routine services of the obstetrician, family physician, midwife, or other provider are subject to this requirement. For the sake of brevity, let’s use the term obstetrician to include all healthcare professionals providing routine prenatal services.
For many years, obstetricians have billed for maternity services using the global obstetrical codes:
59400 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy and/or forceps) and postpartum care
59510 Routine obstetric care including antepartum care, cesarean delivery and postpartum care
59610 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy and/or forceps) and postpartum care, after previous cesarean delivery
59618 Routine obstetric care including antepartum care, cesarean delivery and postpartum care, following attempted vaginal delivery after previous cesarean delivery
These codes now create a problem for payers. Under ACA, payers are required to pay part of the global service as first dollar coverage, while the remainder of the service is subject to policy deductible and co-payment. This leaves payers with two options, neither of which is appealing:
The payer can re-code the global service into antepartum and delivery/postpartum codes.
For instance, 59400 (global vaginal delivery) can be split into 59426 Antepartum care only, 7 or more visits and 59410 Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care. If the payer has an agreed fee schedule with the provider, and the sum of these two codes equals the fee schedule for the global code, this option can work. Although, it likely will require manual adjudication, resulting in payment delay and increased administration costs.
The payer can opt to pay a percentage of the global fee as first dollar, with the remainder subject to policy provisions.
One large national provider recently announced that it will use this option. But because the decision for cesarean section typically does not affect the antepartum care, and the fee schedule for global maternity care varies by the four aforementioned global codes, a fixed percentage payment for antepartum care will also vary. Depending on the chosen percentage, this may result in over or under valuation of the antenatal care services.
There is also a third option:
The obstetrician could submit all claims for global maternity care, splitting the services into the antenatal portion (59425 Antepartum care only; 4-6 visits, 59426) and the delivery portion (59410, 59514 Cesarean delivery only, 59614 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care, 59622 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery; including postpartum care).
Although this may seem like a logical solution, most payers have claims software that considers this unbundling, and will re-bundle the two claim lines into the global service code. To make matters more complicated, some payers may request this split, and others will want the claim bundled to pay a percentage of the total.
OB Panel
In addition to the global maternity care codes, obstetricians routinely order an obstetric panel (80055 Obstetric panel) as part of the first obstetrical visit screening. This panel, by CPT® definition, must include:

  • Complete blood count (several potential codes)
  • Hepatitis B surface antigen (HBsAg) (87340)
  • Antibody, rubella (86762)
  • Syphilis test (86592)
  • Antibody screen, RBC (86850)
  • Blood typing, ABO (86900)
  • Blood typing, Rh (D) (86901)

The ACA spells out that some of these components fall under the United States Preventive Services Task Force (USPSTF) (A) or (B) recommendations requiring first dollar coverage. Specifically, the USPSTF recommends:

  • Routine screening for iron deficiency anemia in asymptomatic pregnant women (B)
  • Screening for hepatitis B virus infection in pregnant women at their first prenatal visit (A)
  • Rh (D) blood typing and antibody testing for all pregnant women during their first visit for pregnancy-related care (A)
  • Screening for all pregnant women for syphilis infection (B)

Although the ACA also requires first dollar coverage of prenatal services, it does not spell out the specifics (other than in reference to the USPSTF recommendations). We don’t know if the intent was to cover the other components of an obstetrical profile at first dollar.
The ACA also requires first dollar coverage of other maternity tests, as spelled out in the USPSTF recommendations, but these are not included in panels (and are outside of the scope of this article). These include screening:

  • For asymptomatic bacteriuria with urine culture in pregnant women at 12 to 16 weeks’ gestation or at the first prenatal visit, if later (B)
  • For chlamydial infection in all pregnant women age 24 years and younger and for older pregnant women who are at increased risk (B)
  • All sexually active women, including pregnant women, for gonorrhea infection if they are at increased risk (i.e., young women or those who have other individual or population risk factors) (B)
  • All  pregnant women for human immunodeficiency virus (HIV), including women in labor who are untested and whose HIV status is unknown (A)

Other USPSTF recommendations not specific to pregnant women may still apply based on age, gender, and risk.
Other Lab Panels
The CPT® codebook lists a number of lab panels that include one or more components of USPSTF recommendations. Like the global obstetrical care codes, this also creates a conundrum for payers. In most cases, the relative value of the USPSTF recommendation that requires first dollar coverage is a small fraction of the relative value of the overall panel. This allows the payer to choose options similar to those outlined under global maternity care:
Pay for only the relative value of the USPSTF recommended component at first dollar, and subject the remainder of the panel to contract provisions.
Pay for the entire panel at first dollar coverage.
There are some inherent difficulties in the first option. Although global obstetrical care can be split into only two components, the panels may include up to 17 components. According to CPT® rules, all components must be performed to use the panel code.
For instance, if the provider bills 80050 General health panel using a screening diagnosis code, USPSTF recommendations require the payer to cover the glucose (82947 Glucose; quantitative, blood (except reagent strip)) component of the comprehensive metabolic panel at first dollar, but leaves the remainder of the panel subject to contract provisions. This is based on the USPSTF recommendation, “The USPSTF recommends screening for type 2 diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg. (B)”
Other panels that include glucose (82947) are:
80047 Basic metabolic panel (Calcium, ionized)
80048 Basic metabolic panel (Calcium, total)
80053 Comprehensive metabolic panel
80069 Renal function panel
Lipid Panel
Code 80061 Lipid panel includes:
82465 Cholesterol, serum or whole blood, total
83718 Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol)
84478 Triglycerides
The USPSTF includes the following lipid screening recommendations:

  • Screening men age 35 years and older for lipid disorders (A)
  • Screening men ages 20 to 35 years for lipid disorders if they are at increased risk for coronary heart disease (B)
  • Screening women age 45 years and older for lipid disorders if they are at increased risk for coronary heart disease (A)
  • Screening women ages 20 to 45 years for lipid disorders if they are at increased risk for coronary heart disease (B)

This appears to require first dollar coverage (based on age and gender) of the lipid panel. The clinical considerations section of the USPSTF recommendations states, however, “The preferred screening tests for dyslipidemia are total cholesterol and HDL-C on non-fasting or fasting samples. There is insufficient evidence of the benefit of including TG (triglycerides) as a part of the initial tests used to screen routinely for dyslipidemia.” This means you could make the argument that only the total cholesterol and HDL portions of the lipid panel are subject to first dollar coverage, and the triglycerides are subject to contract provisions.
Acute Hepatitis Panel
Code 80074 Acute hepatitis panel includes:
86709 Hepatitis A antibody (HAAb); IgM antibody
86705 Hepatitis B core antibody (HBcAb); IgM antibody
87340 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; hepatitis B surface antigen (HBsAg)
86803 Hepatitis C antibody
The USPSTF recommends screening for hepatitis C virus (HCV) infection in patients at high risk for infection. The USPSTF also recommends offering one-time screening for HCV infection to adults born between 1945 and 1965 (the USPSTF hepatitis B recommendation is included under the aforementioned maternity discussion).
Based on this recommendation, only the hepatitis C antibody portion of the acute hepatitis C panel would be covered at first dollar. This panel creates an additional twist because it’s named an “acute” panel; and, based on the included components, one could argue that this panel is not for screening. Therefore, the one component included in the USPSTF recommendation is not being performed for screening and, as such, is not subject to first dollar coverage.
The final area to look at is the screening colonoscopy. The AMA added modifier 33 Preventive service to allow providers to document that—despite the findings at the time of the procedure—the colonoscopy was performed for screening purposes. CPT®, however, does not offer an easy method to distinguish screening from diagnostic.
This would be easier to code and to process claims if the coding were changed to an “add-on” status, where the base code was the colonoscopy (45378 Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure)) and the add-on codes were the procedures. This could be accomplished by adding a semi-colon after the description of colonoscopy (45378) and changing procedure codes 45379-45392 to add-on codes. These codes could then be revalued to reflect only the additional work for each procedure over and above that which is required to perform a screening colonoscopy.
Until, if ever, such a code restructuring takes place, payers are forced to find innovative methods for handling these codes. For example:
Pay the first colonoscopy procedure code as first dollar preventive care, and pay any additional colonoscopy procedure codes—subject to contract provisions—at whatever reduced secondary procedure payment scheme the provider chooses.
Pay only the portion of the first colonoscopy code equal to the payment for a screening colonoscopy without a procedure (45378); pay the remainder of the first procedure code as an initial procedure; and pay any additional colonoscopy procedure codes subject to contract provisions at whatever reduced secondary procedure payment scheme the provider chooses.
Some payers use a hybrid of the second option. Rather than use the standard 50 percent reduction to the second surgical procedure claim, they pay only the portion of the second procedure code that exceeds the value of the base colonoscopy.
The bottom line: Payers and providers must agree to and observe workarounds that allow for proper reporting and reimbursement of many services requiring first dollar coverage under the ACA.
Kenneth D. Beckman, MD, MBA, CPC, CPC-P, CPC-H, CPE, is a family physician, and certified physician executive and chief medical officer of a health insurance company. He is a member of the Milwaukee, Wisc., local chapter.

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Renee Dustman, BS, AAPC MACRA Proficient, is managing editor - content & editorial at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 30 years' experience in journalistic reporting, print production, graphic design, and content management. Follow her on Twitter @dustman_aapc.

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