99461
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
1.26
Facility
$53.11
Non-Facility
$93.86
Documentation Required
- Recommended (per ACOG guidance cited in the CPB) components of prenatal care that women considering home birth should be offered (not described as coverage documentation requirements): 'group B Strep screening and treatment, genetic screening, as well as HIV screening.'
- No specific documentation requirements are stated in this Clinical Policy Bulletin.
- All ICD-10, CPT and HCPCS codes billed for a preventive service should follow standard coding guidelines and be reported with diagnosis and procedure codes that identify the services as preventive and not for treatment of injury or illness.
- Preventive services must be submitted with a designated wellness diagnosis code or maternity diagnosis code in the primary position where indicated (select the appropriate Designated Wellness Code from the pertinent Code Group).
Key Coverage Criteria
- None — Aetna considers planned deliveries at home and associated services not medically appropriate.
- Coverage of home births will be considered when mandated by law under plans subject to state mandates.
- Preventive care services designated by the Affordable Care Act (ACA) and ACA-designated resources (USPSTF grade A or B recommendations; ACIP recommendations adopted by CDC Director; HRSA-supported comprehensive guidelines such as Bright Futures, Uniform Panel of Secretary's Advisory Committee on Heritable Disorders in Newborns and Children, HRSA Women's Preventive Services Guidelines).
- Wellness examinations (preventive medicine comprehensive E/M services) for well-baby, well-child, well-adult and well-woman visits (CPT codes 99381-99387, 99391-99397, 99461; HCPCS G0402, G0438, G0439, S0610, S0612, S0613).
- Age-specific well visit frequencies: ages 0 to 5 per AAP Bright Futures; ages 5 and above annual wellness exam; additional visits for women's contraception management.
- Administration/interpretation of health risk assessment instruments (e.g., suicide risk assessment; sudden cardiac arrest/death risk assessment) (96160, 96161).
2 Active Policies
AETNA-CPB-0329 — Home Births
CIGNA-A004 — Preventive Care Services - (A004)
Related Codes
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