Historically, insurers did not pay for preventive services and providers were trained to always add a condition based diagnosis code to every medical claim. Providers felt they were helping their patients by linking condition codes to these procedures.
Today, the US Preventative Care Guidelines outline what services should be considered as preventative and what frequency is recommended. These services generally include vaccinations, cardiovascular screenings, lifestyle and mental health screenings and limited counseling, and screening for some chronic infections.
These guidelines, however, are unclear to most providers because they do not include common procedural terminology (CPT codes) to clearly state what services are recommended as preventative. Providers may not even be aware that some procedures could be covered as preventive. This has left administrators to establish clinical and administrative policies, resulting in inconsistencies between commercial insurers and government and commercial payers.
One example is the CMS billing requirements that state providers must include a diagnostic code for each service line on claim submission. Administrative policy enacted by the carriers will pay the service based on the diagnostic code provided. So even if a diagnostic test is listed as a preventative service, if it is submitted with an illness diagnostic code, it will pay as medical instead of preventative.
These inconsistencies prove challenging to providers who generally code only one way. Therefore, many continue to code preventive procedures with condition based diagnostic codes so they don’t miss out on reimbursement.
To address this issue, many employers and payers have developed policies to simplify the process. For example, some will pay for the first colonoscopy of the year for members over 50 as a preventive service, regardless of whether a biopsy is performed or not. Many payers will pay for a service that is a preventive service regardless of the age of the patient. Many employers have asked their health plans to share a resource guide with providers defining what services are preventive and how the health plan requests that these be coded. Health plans could improve the member service experience by establishing a rapid appeal process, as these issues are rarely complex and can be easily settled. It’s worth a conversation with your health plan to determine how you can simplify the process.