What Care Codes Are Part of The Affordable Care Act That Midwives Can Bill For?

The implementation of Affordable Care Act (ACA) has greatly influenced the healthcare industry across United States. Study shows that ACA has reduced the number of uninsured people to historically low levels and helped more people access health care services, especially low-income people and people of color. However, the law’s effects on the cost and quality of health care services are difficult to discern given the complexity of our health system.
 
Since its passage, midwives gained opportunities to provide better maternal health access to mothers as the ACA helped to improve the quality of coverage for pregnant and birthing people by requiring individual and small group plans, as well as Medicaid expansion plans, to cover maternity and newborn care.
 
What is Affordable Care Act?
 
Signed into law on March 23, 2010, the Affordable Care Act (ACA) contains numerous provisions impacting a wide range of health care related issues.  The overarching goals of the legislation were to increase the number of people with insurance coverage, improve the design of existing policies, and increase the quality of care provided in the U.S., all while taking significant steps to control costs.
 
Key issues for midwives include:

• Increasing Medicare reimbursement for midwives to 100% of that received by physicians
• Requiring Medicaid programs to provide coverage for birth center services and the services of providers working in birth centers
• Expansion of the eligibility criteria for Medicaid  
• Creation of the new Health Insurance Marketplaces and requirements related to plans offered through the Marketplaces
• Defining the "essential health benefits" (EHB) that must be covered by insurers both inside and outside of the Marketplaces
• Providing assistance for education of midwives 

Under the law, all individual and small employer insurance plans, including those you get through the Marketplace, must cover maternity and newborn care -- before and after your baby is born.* In the past, most plans sold outside your job didn’t offer much maternity coverage. Some didn't cover it at all.
 
The ACA doesn't spell out all of the specific benefits that must be covered while you're pregnant and after the baby is born. But many preventive care services must be covered without extra out-of-pocket costs, like co-pays, co-insurance, or deductibles. For mothers, that includes preventive services for preconception and prenatal care and well-baby check-ups plus comprehensive lactation support, counseling, and breastfeeding equipment. Listed below are the codes included in the Affordable Care Act (ACA) that midwives can bill as they provide services.
 

1. CHLAMYDIA SCREENING LAB TEST*

• CPT CODE(S)
  • 86631 Chlamydia antibody
  • 86632 Chlamydia IGm
  • 87110 Chlamydia culture any source
  • 87270 Chlamydia antigen detection by immunofluorescent technique
  • 87320 Chlamydia antigen detection by enzyme immunoassay technique 87490 Chlamydia direct probe technique
  • 87491 Chlamydia amplified probe technique
  • 87492 Chlamydia quantification 87801 Infectious agent detection by DNA or RNA, direct probe technique
  • 87810 Chlamydia antigen detection by immunoassay with direct optical observation
  • 36415 Venipuncture if performed**
  • 99000 Handling and preparation of specimens if sending to an outside lab, and clinic incurs the cost for transporting them**
• Suggested ICD-10 CODE(S)
  • Z11.8 Encounter for screening for other infectious and parasitic disease†
  • Z11.3 Encounter for screening for infections with a predominantly sexual mode of transmission†

  
     2. GONORRHEA SCREENING LAB TEST*

• CPT CODE(S)
  • 87590 Neisseria gonorrhea, direct probe technique
  • 87591 Neisseria gonorrhea, amplified probe technique
  • 87592 Neisseria gonorrhea, quantification
  • 87801 Infectious agent detection by DNA or RNA, direct probe technique 87850 Neisseria gonorrhea antigen detection by immunoassay with direct optical observation
  • 36415 Venipuncture if performed**
  • 99000 Handling and preparation of specimens if sending to an outside lab, and clinic incurs the cost for transporting them**
• Suggested ICD-10 CODE(S)
  • Z11.3 Encounter for screening for infections with a predominantly sexual mode of transmission†
  • Z11. 2 Encounter for screening for other bacterial diseases†
    

     3. HIV SCREENING LAB TEST*

• CPT CODE(S)
  • 86689 HIV antibody confirmatory test (e.g., Western blot)
  • 86701 HIV-1 antibody 86701
  • HIV-2 antibody 86703 HIV-1 & HIV-2 antibody
  • 87389 Infectious agent antigen detection by immunoassay, EIA, ELISA, IMCA, HIV-1 antigens, HIV-1 and HIV-2 antibodies) 87391 Infectious agent antigen detection by immunoassay, EIA, ELISA, IMCA, HIV-2)
  • 36415 Venipuncture if performed**
  • 99000 Handling and preparation of specimens if sending to an outside lab, and clinic incurs the cost for transporting them**
• Suggested ICD-10 CODE(S)
  • Z11.4 Encounter for screening HIV†
    

     4. SYPHILIS SCREENING LAB TEST*

• CPT CODE(S)
  • 86592 Syphilis test, qualitative (e.g., VDRL, RPR)
  • 86593 Syphilis test, quantitative (e.g., VDRL, RPR)
  • 36415 Venipuncture if performed**
  • 99000 Handling and preparation of specimens if sending to an outside lab, and clinic incurs the cost for transporting them**
• Suggested ICD-10 CODE(S)
  • Z11.3 Encounter for screening for infections with a predominantly sexual mode of transmission†
  • Z11.2 Encounter for screening for other bacterial diseases

 
   5. BEHAVIORAL COUNSELING TO PREVENT SEXUALLY TRANSMITTED INFECTIONS(If the patient has sign, symptom, or has been exposed to an infection, use appropriate ICD-10 code and 99201–99215)

• CPT CODE(S)
  • 99401 Preventive counseling or risk factor reduction: 15 mins‡
  • 99402 Preventive counseling or risk factor reduction: 30 mins‡
  • 99403 Preventive counseling or risk factor reduction: 45 mins‡
  • 99404 Preventive counseling or risk factor reduction: 60 mins‡
• Option 2

• New patient problem visit: 99201-99205 Established patient problem visit: 99211-99215
• These visits may also be reported based on counseling time. If counseling or coordination of care accounts for more than 50% of the visit, then select the E/M code (99201–99215) based on the length of the visit. Not all payers will reimburse these codes with a corresponding ICD10 preventive service Z code. For private insurance, append modifier 33 to the E/M code to indicate it is a preventive service

• Suggested ICD-10 CODE(S)
  • Z71.7 Human immunodeficiency virus [HIV] counseling
  • Z71.89 Other specified counseling (other than HIV)

 
   6. CONTRACEPTIVE COUNSELING(If the patient has a side effect from current method or menstrual irregularity, use ICD-10 code for sign or symptom and 99201–99215. When a patient presents with a problem, it is not appropriate to report a preventive CPT code)

• CPT CODE(S)
  • 99401 Preventive counseling or risk factor reduction: 15 mins‡
  • 99402 Preventive counseling or risk factor reduction: 30 mins‡
  • 99403 Preventive counseling or risk factor reduction: 45 mins‡
  • 99404 Preventive counseling or risk factor reduction: 60 mins‡
• Option 2
  • New patient problem visit: 99201-99205 Established patient problem visit: 99211-99215
  • These visits may also be reported based on counseling time. If counseling or coordination of care accounts for more than 50% of the visit, then select the E/M code (99201–99215) based on the length of the visit. Not all payers will reimburse these codes with a corresponding ICD10 preventive service Z code. For private insurance, append modifier 33 to the E/M code to indicate it is a preventive service

• Suggested ICD-10 CODE(S)
  • Z30.09 Encounter for other general counseling and advice on contraception
  • Z30.02 Counseling and instruction in natural family planning to avoid pregnancy

 
   7. WELL WOMAN VISIT(Some payers expect that many of these ACA preventive services—counseling, screening, and immunizations—occur during the annual preventive exam and may not reimburse separately for these on the same day or at subsequent visits.)

• CPT CODE(S)
  • Preventive visits for new patients by age: 99381, 99382, 99383, 99384, 99385, 99386, 99387
  • Preventive visits for established patients by age: 99391, 99392, 99393, 99394, 99395, 99396, 99397
• Suggested ICD-10 CODE(S)
  • Z01.411 Encounter for gynecological examination (general) (routine) with abnormal findings
  • Z01.419 Encounter for gynecological examination (general) (routine) without abnormal findings
  • Z00.00 Encounter for general adult medical examination without abnormal findings
  • Z00.01 Encounter for general adult medical examination with abnormal findings Note: These may only be used with preventive visit for new or established patients
• HCPCS CODE(S) Medicare & some commercial payers
  • G0402 Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment
  • G0438 Annual wellness visit; includes a personalized prevention plan of service, initial visit
  • G0439 Annual wellness visit, includes a personalized prevention plan of service, subsequent visit
  • S0610 Annual gynecological examination, new patient
  • S0612 Annual gynecological examination, established patient
  • S0613 Annual gynecological examination; clinical breast examination without pelvic evaluation
    

     
     8. HUMAN PAPILLOMAVIRUS (HPV) VACCINATIONS
(If not administered during an annual wellness exam, some payers will also reimburse for an office visit)

• CPT CODE(S)
  • 90649 Gardasil® 90650 Cervarix®
  • 90651 Gardasil 9®
  • 90460 Administration of vaccine through age 18 with counseling by provider—any route, 1st
  • 90461 ADD ON CODE: Administration of vaccine through age 18 with counseling by provider—any route, each additional during that encounter 90471 Administration of vaccine over 18—any route, 1st
  • 90472 ADD ON CODE: Administration of vaccine over 18—any route, each additional during that encounter Requires a CPT code for the immunization and a CPT code for the administration
• Suggested ICD-10 CODE(S)
  • Z23 Encounter for immunization
    

     9. HPV DNA LAB TESTING

• CPT CODE(S)
  • 87623 HPV detection by DNA or RNA, low risk
  • 87624 HPV detection by DNA or RNA, high risk
  • 87625 HPV detection by DNA or RNA, types 16 and 18, includes type 45 if performed
• Suggested ICD-10 CODE(S)
  • Z11.51 Encounter for HPV screening
    

    10. HEPATITIS (Hep) A IMMUNIZATION (If not administered during an annual wellness exam, some payers will also reimburse for an office visit)

• CPT CODE(S)
  • 90632 Hep A adult dosage
  • 90633 Hep A pedi/adolescent 2-dose schedule
  • 90634 Hep A pedi/adolescent 3-dose schedule
  • 90636 Hep A and Hep B adult dosage 90460 Administration of vaccine through age 18 with counseling by provider—any route, 1st
  • 90461 ADD ON CODE: Administration of vaccine through age 18 with counseling by provider—any route, each additional during that encounter
  • 90471 Administration of vaccine over 18—any route, 1st
  • 90472 ADD ON CODE: Administration of vaccine over 18—any route, each additional during that encounter
  • Requires a CPT code for the immunization and a CPT code for the administration
• Suggested ICD-10 CODE(S)
  • Z23 Encounter for immunization

 
    11. HEPATITIS (Hep) B IMMUNIZATION I(If not administered during an annual wellness exam, some payers will also reimburse for an office visit.)

• CPT CODE(S)
  • 90636 Hep A and Hep B adult dosage
  • 90739 Hep B adult 2-dose schedule
  • 90740 Hep B for immunosuppressed 3-dose schedule
  • 90743 Hep B adolescent 2-dose schedule
  • 90744 Hep B pedi/adolescent 3-dose schedule
  • 90746 Hep B adult 2-dose schedule 90747 Hepatitis B for immunosupressed 4-dose schedule
  • 90460 Administration of vaccine through age 18 with counseling by provider—any route, 1st
  • 90461 ADD ON CODE: Administration of vaccine through age 18 with counseling by provider—any route, each additional during that encounter
  • 90471 Administration of vaccine over 18—any route, 1st
  • 90472 ADD ON CODE: Administration of vaccine over 18—any route, each additional during that encounter
  • Requires a CPT code for the immunization and a CPT code for the administration

• Suggested ICD-10 CODE(S)
  • Z23 Encounter for immunization

 
​     12. Sexually transmitted infection prevention counseling 

• CPT — A list of sexually transmitted infection CPT codes can be found here. 
• Eligibility: ACA expanded coverage for all adults at high risk of contracting a sexually transmitted disease. 

 
References

Adviser, C. S. S., Seeberger, C., Adviser, S., Director, M. C. A., Coleman, M., Director, A., Shepherd Director, M., Shepherd, M., Director, Director, E. L. A., Lofgren, E., Gordon Director, P., Gordon, P., Director, J. P. S., Parshall, J., Director, S., Williamson, H., Taylor, J., Tausanovitch, A., … Conner, A. (2022, June 9). Building on the ACA: Administrative actions to improve maternal health. Center for American Progress. Retrieved September 28, 2022, from https://www.americanprogress.org/article/building-aca-administrative-actions-improve-maternal-health/

Affordable care act (ACA) - glossary. Glossary | HealthCare.gov. (n.d.). Retrieved September 28, 2022, from https://www.healthcare.gov/glossary/affordable-care-act/

Lamboley, L. (2022, September 19). List of Aca Preventive Services and CPT codes [Prevounce Quick Guide]. Prevounce Blog. Retrieved September 28, 2022, from https://blog.prevounce.com/list-of-aca-preventive-services-and-cpt-codes-prevounce-quick-guide

List of Aca Preventive Services and CPT Codes - Std Tac. (n.d.). Retrieved September 28, 2022, from http://stdtac.org/wp-content/uploads/2014/06/List-of-ACA-Preventative-Services-and-CPT-Codes-_STDTAC.pdf