Understanding Evidence Statements, Summary Plan Descriptions (SPDs) and CPT Codes

Each clinical preventive service in the Purchaser's Guide includes an evidence statement, summary plan description (SPD) language and appropriate CPT codes. An explanation of these components is detailed below.

For condition-specific information, see Clinical Preventive Services A - Z Index.

Evidence Statements

Overview
Evidence statements provides the scientific evidence behind each of the screening, testing, counseling, immunization, preventive medication and preventive treatment benefit recommendations in the Purchaser's Guide.

Evidence Statements in the Purchaser's Guide
Each evidence statement in the Purchaser's Guide contains:

• A description of where the recommendation information originated,
• Condition / disease-specific information,
• The level of evidence used in constructing the recommendation,
• The strength of the evidence determined by the strength of scientific evidence supporting a clinical preventive service and the magnitude of net benefit (defined as benefits minus harms),
• The economic burden, workplace burden and estimated cost of a specific condition or disease,
• The value of implementing the recommended preventive intervention.

Summary Plan Description (SPDs) Language

Overview
The Purchaser's Guide provides 46 condition-specific SPD language statements designed to assist benefits staff as they design, discuss, negotiate and set benefit structures and coverage guidelines with a health plan, union or consumer group.

Generally, SPDs:

• Outline healthcare services covered in the plan.
• Describe how services are provided and how the plan(s) operate.
• Describe how benefits are calculated.
• Explain the portion of costs for which the plan is responsible and the portion of costs for which the beneficiary is responsible (e.g., copays, coinsurance).

Summary Plan Descriptions in the Purchaser's Guide
The Purchaser's Guide contains condition, disease or injury specific SPD language statements for each clinical preventive service recommended. The SPD language statements clearly outline the recommended benefits for each service. The recommended benefits and SPDs are a translation of the clinical guidelines featured in the corresponding evidence statements, which outline the medical evidence for each intervention.

Current Procedural Terminology (CPT®) Codes

Overview
CPT codes are provided for employers and health plans to facilitate the implementation and reimbursement of clinical preventive service benefits. CPT codes are five digit numeric codes developed by the American Medical Association (AMA). They provide a uniform language that accurately describes medical, surgical and diagnostic services.

The list of codes is updated annually. For more information on CPT codes and to view updates, please contact the CPT Information and Education Service at 1-800-634-6922 or visit: American Medical Association, CPT-Current Procedural Terminology.

CPT® Codes in the Purchaser's Guide
Applicable current procedural terminology (CPT) codes are provided for each recommended benefit. Employers who adopt the recommendations set forth in the Purchaser's Guide should ensure that their health plan administrators approve the listed CPT codes for provider reimbursement. For a full list of CPT codes included in the Purchaser's Guide, please click here.

References:

¹ Agency for Healthcare Research and Quality. The Guide to Clinical Preventive Services: Recommendations of the U.S. Preventive Services Task Force. Rockville, MD: Agency for Healthcare Research and Quality; 2005.