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Preventative Services vs Diagnostic

Jamie Posted Wed 30th of March, 2016 17:41:08 PM

When it comes to preventative services for labs, if a patient comes in for a preventative exam and labs, and they have Hyperlipidemia, and on medication, we run a lipid panel which we would bill diagnostic vs a preventative screening for hyperlipidemia, since we can't screen the patient for a condition they already have...but per UHC Preventative Services, they are saying this would be a screening and not billed under diagnostic because the blood test is considered preventive care because they are part of her overall wellness exam.
This goes against everything we have been tough... What is the appropriate and correct way because this just makes me confused...... Please Help... Thank you

SuperCoder Answered Thu 31st of March, 2016 02:39:24 AM

Good day!
As per UHC guidelines, certain services can be done for preventive or diagnostic reasons. When a service is performed for the purpose of preventive screening and is appropriately reported, it will be adjudicated under the Preventive Care Services benefit.
Blood drawing (venipuncture or finger or heel stick) is considered as payable under the preventive benefit if billed for a preventive lab service that requires a blood draw.
THANKS.

Jamie Posted Thu 31st of March, 2016 15:29:34 PM

So if the patient has a current condition such as hyperlipidemia, and they come in for preventative exam and labs, and they get a lipid panel, we can bill the lipid as a screening preventative, even though the patient already has hyperlipidemia? I have always been told that you cannot screen a patient for a condition they already have, so do payer guidelines override all the training that is out there regarding prev vs diagnostic?

SuperCoder Answered Fri 01st of April, 2016 07:09:10 AM

Hi,
You are absolutely correct that you cannot screen a patient for a previously diagnosed/known condition. Diagnostic services are done on a person who had abnormalities (e.g. hyperlipidemia) found on previous preventive/diagnostic studies that require further diagnostic studies (e.g. lipid panel). So in this case, you can bill lipid panel as diagnostic.
If the patient had abnormal results on prior preventive screening and the diagnosis has been made, then further testing is considered diagnostic rather than preventive.
Thanks.

Jamie Posted Wed 05th of April, 2017 18:28:38 PM
Good Afternoon, Our billing office "scrubs" invoices with provider dictation before billing charges out so our claims go out as clean as possible. If a provider is ordering a Preventative lab test (Ex: Lipid Panel- Screening for Lipid Disorders)and also treating the patient for Hyperlipidemia. Before the lab order goes out it gets scrubbed with Hyperlipidemia vs Screening due to the patient already having the condition. My provider has asked me not to correct her coding and leave it as preventative...but per coding guidelines I cannot bill a preventative test due to the patient already being diagnoses with the condition. Since insurance covers several preventative tests a year they want all the tests billed as preventative since they get the benefit. I was under the understanding a preventative test cannot be preventative if the patient has a diagnosis/sign or symptom(Ex: Cant screen patient for Diabetes Mellitus when the patient is already diabetic or abnormal glucose).. Please Help as we are being asked of something that goes against coding regulations. Thank you
SuperCoder Answered Thu 06th of April, 2017 04:34:14 AM

Hi,

 

You cannot screen a patient for a previously known condition. Diagnostic services are done on a person who had known abnormalities (e.g. hyperlipidemia). You can bill lipid panel as diagnostic.

 

Cardiovascular screening blood tests are covered for all asymptomatic members for early detection of cardiovascular disease or abnormalities associated with an elevated risk of cardiovascular disease. This screening includes total cholesterol test, cholesterol test for high density lipoproteins and triglycerides test. Frequency is every five years (i.e., 59 months after the last covered screening tests).

 

Coverage frequency varies depending on the member’s plan. Under some plans, cardiovascular screening may be covered at more frequent intervals than Medicare criteria allow. Therefore, refer to the member’s EOC/SOB for the member’s specific benefit coverage for cardiovascular screening.

 

Please refer to the following link for more information:

https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools and Resources/Policies and Protocols/UnitedHealthcare Medicare Coverage/Preventive_Services_UHCMA_CS.pdf

Thanks.

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