Screening for Depression: How Policies Differ Across the Four Largest US Insurance Companies

Depression is one of the most common mental health illnesses in the U.S., affecting children, adolescents, adults and the elderly. In a given year, approximately 16.1 million (6.7%) adults ages 18 or older, 2% of children and 5-8% of adolescents suffer at least one major depressive episode.

Characterized by persistent sadness and loss of interest, depression can affect thoughts, feelings, and behaviors. Depressed individuals display symptoms including changes in sleeping, eating, energy and concentration. Depression is also the most common mental illness in those who commit suicide. Notably:

• More than a quarter of individuals with major depression who commit suicide are obtaining psychiatric services at the time of their death.
• Approximately 50% of those who commit suicide saw their general practitioner during the three months leading up to their death.
• 40% of individuals saw their practitioner the month prior to their death.
• 20% of individuals were seen within a week of their death.

Due to the high prevalence of depression and the potentially devastating outcomes of untreated depression, appropriate and timely screenings are vital.  Screening for depression may need to occur throughout the lifespan and across healthcare settings. Therefore, providers in a range of specialties such as Internal Medicine physicians, OBGYNs, Pediatricians and Geriatricians, may all be called upon to provide depression screenings.

The Affordable Care Act, the healthcare reform law passed in 2010, required that all Marketplace health plans and many other plans cover depression screening without patient cost-sharing. In order to identify how medical healthcare professionals can be reimbursed for depression screening services, we reviewed current commercial policies on screening of depression among four of the largest health insurers in the U.S.: Aetna, Cigna, UnitedHealthcare, and Anthem BCBS. 

Table 1 below presents a summary of depression screening policies for these insurers and their corresponding CPT and HCPCS codes for obtaining reimbursement for these services (when using CPT 96127 and / or HCPCS S0302).

Table 1: Insurance Policies for Screening of Depression with Corresponding CPT and HCPCS Codes

	Policy	CPT and HCPCS Codes
Cigna	Depression screening is covered under the ACA, without cost sharing to members when provided by Network physicians. Depression screening may be administered as part of a wellness examination.  Frequency of Wellness Exams: 1a. Ages 0 to 5:  According to the American Academy of Pediatrics (AAP) Bright Futures Periodicity Schedule 1b. Ages 5 and above: Annual wellness examination Preventative Care Screenings and Interventions may be provided as part of a wellness examination or at a separate encounter: 2. Annual Depression Screening: adolescents and adults including pregnant and postpartum women	Billed in conjunction with any of the following codes 1a. 99381, 99382, 99391, 99392, 99461 Allowed with any diagnosis code 1b.  99383, 99384, 99385, 99386, 99387, 99393, 99394, 99395, 99396, 99397, G0402, G0438, G0439, S0610, S0612, S0613 Allowed with any diagnosis code 2. G0444 Allowed with any diagnosis
United Health care	Depression screening is covered under the ACA, without cost sharing to members when provided by Network physicians. 1a. Depression Screening in Children and Adolescents USPSTF Rating (Feb. 2016): B The USPSTF recommends screening for major depressive disorder (MDD) in adolescents aged 12 to 18 years. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. 1b. Screening for Depression in Adults USPSTF Rating (Jan. 2016): B Recommendation: The USPSTF  recommends screening for depression in the general adult population, including pregnant and postpartum women. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.	1a. 96127, G0444 ICD-10-Diagnisis Code Z13.89 required for 96127 only 1b. 96127, G0444
Anthem BCBS	Depression screening is covered under the ACA, without cost sharing to members when provided by Network physicians. 1. Child preventative care – screening tests: Depression screening 2. Adult preventative care – screening tests: Depression screening	Codes were not provided with this policy.
Aetna	Depression screening is covered under the ACA, without cost sharing to members when provided by Network physicians. 1a. Depression screening is covered in all adolescents age 11-19 during annual physical exams. 1b. Depression screening is covered for ages 13 to 19 years during annual physical exams. 1c. Depression screening is covered in all adolescents at risk ages 11-19 during or outside of physical exams. 1d. Depression screening for adults is a covered preventative service with no member cost sharing. 2. Depression in Primary Care Program designed to support the screening for and treatment of depression at the primary care level.	96127 in conjunction with ICD-10-Diagnisis Code Z13.89

Our review revealed some differences between the Payers.  One difference found was in the specification of age categories and allowable frequency of screening within those age categories:

• Cigna cites coverage policies in three instances: congruent with Bright Futures guidelines (0-5 years of age), annually from ages 5 years and up as part of wellness exams, and in adults as a yearly screening with or without a wellness exam.
• UHC’s policy recommends depression screening in adolescents (defined as ages 12 to 18) and for all adults. 
• Anthem does not specify ages in their policy, and
• Aetna covers screening at any time for at risk adolescents (defined as ages 11 through 19) and annually for members 11 through 19 who are not at risk.

Other differences included:

• The specific mention of pregnant and/or postpartum women by Cigna and UHC.
• Mention of screenings being performed during annual physical exams by Cigna and Aetna. 
• Differing policies were cited as the basis for screening recommendations:
  • Cigna – Bright Futures Periodicity Schedule
  • UHC – U.S. Preventative Services Task Force (USPSTF)
• A mention of screening for Major Depressive Disorder (MDD) specifically by UHC. MDD is typically what is referred to simply as “depression” but a Depressive Episode may be a part of MDD an isolated event.
• Aetna differentiates between adolescents who are at risk with those who are not at risk, specifying that adolescents not at risk can receive screenings annually during physical exams but does not mention any such limitations for at risk youth.
• UHC specifies the acceptable environment and procedures for screening stating that “Screenings should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.”
• Aetna offers a Primary Care Program to support screening in this setting.

One notable similarity among all four insurers was that within the specified age ranges and frequencies, depression screenings provided by in-network physicians were covered with no patient cost-sharing (i.e. copayments, co-insurance, and deductibles).

Given the variation in ages and frequency however, it is recommended that your practice periodically review behavioral health screening policies to ensure that you are complying with the terms required by each insurer to appropriately seek reimbursement.