The Affordable Care Act aka Obamacare ensures access to free preventative measures, allowing medical professionals to catch medical issues before they become severe, or better yet, to prevent them from developing in the first place. In order to accomplish this lofty aim, patients are encouraged to schedule regular checkups, at which preventive measures such as screenings and vaccinations may be pursued. Many of these services are offered at minimal cost or are completely covered by insurance plans.
Although prevention and diagnosis often are lumped into the same category, they describe completely disparate types of medical care with different coverage options and payment plans. The two may occasionally experience some overlap, such as when a medical issue is highlighted during a preventative screening. Even then, medical billing procedure separates the preventative screening from any further tests used to obtain a diagnosis.
Preventative Care
The goal of preventative care is to maintain a reasonable baseline of health, so as to reduce the likelihood of major diseases and conditions in the future. Often, this means encouraging activities and behaviors that will result in better health outcomes. Preventative measures can also be used to detect medical issues for which, due to heredity and other factors, patients may be susceptible. Patients cannot be charged copays or coinsurance for the following preventative measures:
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Blood pressure screening
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Cholesterol screening
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Depression screening
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HIV screening
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Diet counseling
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Cessation intervention for tobacco users
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Type 2 diabetes screening
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Mammograms and breast cancer prevention
A number of vaccines are also covered under the preventative care stipulations in the Affordable Care Act, including hepatitis A and B, tetanus, human papillomavirus (HPV) and diphtheria, among others.
If other medical issues are noted during medical screenings, ensuing care may be covered under preventative coding and billing in certain situations. However, in most situations, everything that occurs after the screening will be coded as diagnostic.
Diagnostic Services
Preventative screenings often alert physicians to major medical problems, which, following the screening, may require further examination. Any tests or procedures conducted during this process may be deemed diagnostic for purposes of medical billing. The main exception involves preventative colonoscopy screenings; if a polyp is discovered and removed during the same visit, the entire procedure is coded as preventative.
A great deal of confusion stems from tests that, depending on the patient’s reason for scheduling an appointment, could be considered preventative or diagnostic. Mammograms are particularly apt to cause confusion; when used as a screening tool, they are deemed preventative and thus, fully covered by insurers. But for patients visiting due to lumps or pain, the screening may be coded as diagnostic.
Coding For Preventative And Diagnostic Services
Medical coding for preventative and diagnostic care can be complex, particularly if both types of care take place during the same visit. Preventative services should be marked with the appropriate CPT codes, with additional designation required for measures considered preventative only when pursued by Medicare members. If diagnostic services are required during a prevention-based visit, the medical coder can include the appropriate E&M diagnostic codes with the preventative encounter. The same procedure may be considered preventative or diagnostic depending on the circumstances of the visit, so it is important to thoroughly document all patient data collected during the encounter.
Due to the complicated nature of preventative and diagnostic billing, many clinics and practices choose to avoid payment issues by offering patients documents that cover the differences in medical coding procedure for preventative and diagnostic services. Patients are encouraged to read and sign these documents before receiving medical care. Even with the presence of disclaimers, some degree of confusion among patients is to be expected.
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