Blue Cross Newsletter

November 19, 2010


To: All Blue Cross Contracting Providers

Cindy Garrison, CPC – Education/Communication Coordinator
Institutional Relations
Blue Cross and Blue Shield of Kansas, Inc.
An Independent Licensee of the Blue Cross and Blue Shield Association


Health Care Reform – Preventative Services

Preventive Health Benefits under Health Care Reform are a result of the clinical recommendations of the U.S. Preventive Services Task Force (USPSTF): Guide to Clinical Preventive Services and the recommendations of the Advisory Committee on Immunization Practices (ACIP), in addition to other nationally recognized sources. 

The Affordable Care Act (ACA) portion of the law created a category of preventive services to be paid without cost sharing on behalf of the member. A complete list of these services may be found at

Blue Cross and Blue Shield of Kansas (BCBSKS) has applied these recommended Preventive Services to all BCBSKS insureds whose coverage has not been grandfathered as defined by the legislation. In some cases the BCBSKS grandfathered health plan has adopted the preventive health services into its current plan.

Grandfathered Health Plans –

The grandfathering provision of the ACA allows individuals and employers to maintain their existing insurance coverage so long as they were enrolled on the date of the law's enactment on March 23, 2010. The grandfather provision requires the employer to provide notice to their employees of the Health Plan's grandfathered status. Your BCBSKS patients should have received such a notice from their employer. Providers may also contact Customer Service at the numbers identified on the member ID card. The ACA does not require that 100 percent of preventive benefits be added to grandfathered plans.

Non-Grandfathered Health Plans –
All non-grandfathered plans must provide the ACA's recommended Preventive Health services   without cost share to the insured. For plans beginning on or after Sept. 23, 2010, all deductibles, coinsurance or co-payments are to be waived, and the health plan will pay 100 percent of the plan allowance (subject to medical necessity and medical management guidelines) to the BCBSKS contracting provider.

Annual Wellness/Preventive Services –

Annual wellness or preventive services are typically provided by a primary care type provider such as Family Practice, General Practice, Internal Medicine, Pediatrics, and in some cases, the Gynecological specialist. In some instances the preventive service may be provided in an outpatient setting. The preventive medicine services section in CPT® defines the difference between preventive services, office/outpatient services, and when it is appropriate to use the counseling risk factor reduction and behavior change intervention set of codes. Each set of codes has a defined intent on what the codes include and what may be billed separately or in addition to a service being provided. Providers are asked to review these codes and apply the codes appropriately to the services being provided. The periodic comprehensive preventive CPT® codes for an annual wellness exam with anticipatory guidance will be allowed with no cost-sharing once per benefit period for members older than 3 years.

Coding for Preventive Health Benefits –

BCBSKS expects providers performing annual wellness examinations to use the Preventive Medicine Service codes in the Evaluation and Management (E/M) section of CPT®. Providers rendering counseling, risk factor reduction and behavior change modification are expected to use the specific codes for these services. The BCBSKS member benefits will be processed according to the CPT® code and diagnosis code billed. The codes submitted should be ones that best represent the services provided. Services related to counseling and behavior change modification are allowed a defined number of hours per benefit period. The hours will be calculated using the time defined in the CPT® codes for those services.

When elements of a preventive service are split between two providers, it is expected that the provider who renders the majority of the wellness or preventive service will bill the Preventive Services E/M code, and the provider who renders a specific portion of an annual well visit will bill the office or outpatient E/M code in addition to the ancillary preventive services, i.e., lab, x-ray, which would be paid at no cost share to the patient for these ancillary services.

A quick reference guide, available at the link below, provides a summary of the ACA's Preventive Health Benefits with BCBSKS recommended CPT® and diagnosis codes. This information does not supersede preventive health services that may already be part of a member's contract. Insureds who have Preventive Services as defined by their current benefits will maintain those preventive benefits in addition to the new standard Preventive Health Benefits. In situations where there is an overlap in the member contract on preventive services, the member will receive only one of the preventive services or as defined by the member contract.

The services with a heart indicate the service is included in the annual preventive visit code. Counseling and risk factor services are identified with a check mark. Lab services included in an obstetric panel are noted with a boxed "x". The specific CPT® code and indicated diagnoses codes would be allowed once annually to contracting providers with no cost share.

To view the quick reference guide for submitting claims for preventative services, click here.

For a complete list of preventive services, please visit: