CurrentHighmark DelawarePolicy N/A

USPSTF perinatal depression prevention counseling coverage

Guidance for clinicians and billing staff on Highmark Delaware's preventive coverage and coding recommendations for USPSTF-recommended counseling to prevent perinatal depression for pregnant and up to 1 year postpartum persons at increased risk.

Policy Summary

PayerHighmark Delaware

PolicyUSPSTF perinatal depression prevention counseling coverage

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2020

Next Review DateN/A

Key ActionBill preventive counseling and behavioral assessment CPT codes (e.g., 99401-99404, 96156-96171) for at-risk pregnant and <1 year postpartum persons and omit codes related to drug management.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1.1.2020policy effective date for preventive coverage guidance

pregnant & <1yr pptarget population per USPSTF

99401-99404, 96156-96171example counseling/assessment codes provided

USPSTF median = 8frequency reference

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Coverage criteria for preventive perinatal depression counseling

Covered when ALL of the following are met:

ALL of the following

This guidance supplements the USPSTF recommendation by providing coding and coverage context effective 1/1/2020
Highmark policy effective date
USPSTF reported median counseling frequency = 8 (document notes frequency 20 in studies)
Frequency reference for counseling interventions

ALL of the following

Providers should verify individual member benefits via Availity for specific coverage determinations
Reference to checking member's health benefit plan

Suggested CPT and Assessment Codes; Frequency

Suggested CPT/assessment codes for preventive counselingCPTCovered

99401	Preventive med counseling and/or risk factor reduction intervention(s) - individual; 15 min
99402	Preventive med counseling and/or risk factor reduction intervention(s) - individual; 30 min
99403	Preventive med counseling and/or risk factor reduction intervention(s) - individual; 45 min
99404	Preventive med counseling and/or risk factor reduction intervention(s) - individual; 60 min
96156	Health behavior assessment
96158	Individual counseling (behavioral health treatment) - variant
96159	Individual counseling (behavioral health treatment) - variant
96167	Family counseling with patient present
96168	Family counseling with patient present
96170	Family member counseling without patient present

1–10 of 11

1/2

CODING — Frequency reference

USPSTF median frequency (reported)8 (USPSTF median frequency) — Highmark notes frequency = 20

Highmark effective dateEffective 1/1/2020 (guidance to assist implementation and coding)

Age restrictionNone

Billing and Coding Guidance for Providers

Billing Rule

Billing and coding guidance — use preventive counseling/assessment codes; exclude drug‑management codes

Bill preventive counseling and behavioral/health assessment CPT codes (examples: 99401–99404; 96156, 96158–96159, 96167–96171) when delivering USPSTF-recommended perinatal depression prevention counseling to pregnant persons and those <1 year postpartum without a current diagnosis of depression. Do not use codes that include drug management or imply treatment of a diagnosed depressive disorder; mental health treatment for diagnosed depression should be billed under the member's medical benefits.

Use preventive counseling and assessment codes for perinatal depression prevention counseling (e.g., 99401–99404; 96156, 96158–96159, 96167–96171).
Exclude codes that include drug management since the target population is persons without a current depression diagnosis.
If a psychiatric or current depression diagnosis is present, bill mental health treatment under the member’s medical benefits rather than preventive counseling codes.
Verify individual member coverage via Availity as plan benefits may vary; Highmark’s preventive coverage effective 1/1/2020.

Definitions and At-Risk Population Details

DEFINITIONS — Individuals at increased risk

Target populationPregnant persons and persons less than 1 year postpartum without a current diagnosis of depression

Risk factors (examples)History of depression; current subthreshold depressive symptoms; certain socioeconomic factors (low income, adolescent or single parenthood); recent intimate partner violence; elevated anxiety symptoms; history of significant negative life events

Additional risk factorsPersonal or family history of depression; history of physical or sexual abuse; unplanned or unwanted pregnancy; current stressful life events

DEFINITIONS — Drug management exclusion

Exclusion of drug management codesCodes that include drug management were intentionally left out because drug management indicates a diagnosis and the targeted population is persons without a current depression diagnosis

Implication for billingBill preventive counseling and assessment CPT codes (e.g., 99401-99404, 96156-96171) rather than pharmacologic management codes for this preventive service

Coverage boundaryMental health treatment for diagnosed depression is covered under the member's medical benefits (not preventive counseling)