Preventative = Screening (no symptoms or problems are present)

Most insurance companies consider preventive service(s) as those which are provided to help a member avoid becoming sick, thus minimizing the risk of incurring costly medical procedures. Preventative services generally include, but are not limited to; wellness physicals or tests/screenings done on a yearly basis, such as mammograms, eye exams, pap smear, prostate screening, etc.

Preventative (screening) tests and services are performed when the patient has no signs or symptoms to suggest that they are not healthy. Screening is the process of testing for disease or disease precursors in seemingly well individuals so that early detection and treatment can be provided for those who test positive for the disease. Preventative screenings are those that are recommended based on age or risk factors, such as colonoscopy at age 50, cancer screenings for those at high risk.

Most health insurance plans must cover a set of preventive services – like shots and screening tests. See the list of covered preventive care covered for all adults, pregnant women or women who may become pregnant, women, and children. Medicare beneficiaries are also eligible to receive a annual wellness visit, with no out-of-pocket costs.

Medical = Diagnostic or Therapeutic (symptoms or problems exist)

Medical services are those which are recommended by a doctor in order to diagnose symptoms, or treat or monitor a known medical condition, health problem, or disease. Any testing being done is considered diagnostic testing and not screening (preventative). Diagnostic services done on a routine basis include items such as high blood pressure check, diabetes check, thyroid check etc.

Diagnostic testing is done when the member is experiencing symptoms or health problems. Tests and/or procedures are ordered to assist in determining the cause of the symptoms and/or performed to obtain information to aid in the assessment of a medical condition, identify a disease and/or to determine the nature and severity of an ailment or injury. In addition, the monitoring of an existing health condition (such as diabetes or high cholesterol) is not a preventive service.

Member Financial Concerns

Many insurance companies now offer preventative care services at no cost to their members. Meanwhile, medical services often requires the member to satisfy their deductible and pay coinsurance amounts. It is important that you understand the type of service being rendered to avoid unexpected bills from the hospital as both preventative care and medical care can be provided during a single hospital and/or clinic visit.

Provider Medical Coding Guidelines

Most insurance carriers require adherence to insurance claim coding guidelines as follows.

Medical coding staff are responsible for assigning the principle diagnosis, which is defined in the Uniform Hospital Discharge Data Set as “that condition established after study to be chiefly responsible for the patient seeking health care.”

In light of these guidelines, it would not be appropriate for a provider to “code in a manner that would allow medical services to be considered preventative” in order for insurance to pay in full when in fact medical services were rendered as this would be considered fraudulent.