Preventative vs. Diagnostic Services in the Affordable Care Act

April 4, 2014
Matt Dallmann

Physicians and medical practice staff must be able to differentiate between preventative and diagnostic services in order to avoid a loss in revenue.

Under the Affordable Care Act, insurance plans now cover preventative care without patient cost sharing, i.e., without co-pays, co-insurance, or deductibles.  However, services that are not classified as preventative care are still subject to cost sharing. It is important for physicians and their staff to be able to differentiate between the two in order to avoid blindsiding patients and avoid experiencing a revenue loss.

Since the average deductible on plans offered through the state and federal health insurance exchanges is between $1,000 and $6,000, financial responsibility for a non-preventative visit could easily fall on the patient.

To clarify, here are a few examples of preventative care and diagnostic care.

Preventative services:
• If an abnormal finding on a preventative mammography screening is later found to be normal, then the future mammography screening is considered preventative. 
• If a polyp is removed during a preventative colonoscopy screening, the removal of the polyp, and any associated lab and facility fees, performed during the same encounter, are considered preventative. 

Diagnostic services:
• If an abnormal finding on a preventative mammography screening is later confirmed to be abnormal, then the future mammography screening is considered diagnostic, and any deductible, co-pay, or co-insurance is applied. 
• If a polyp is removed during a preventative colonoscopy, any future colonoscopies are considered diagnostic, because the time intervals between future scopes are shorter. 

The first step for avoiding confusion between preventative and diagnostic care lies in the hands of the medical coder and biller. Preventative services must be coded with the appropriate CPT codes, diagnosis codes, and modifiers.  Diagnostic services or problem related E&M codes can be reported on the same encounter, with the appropriate modifier and diagnosis, and, depending on the payer’s policies, be paid at 50 percent of the contracted rate.  If coders know the difference between the two, and can code correctly with supporting documents as a backup, they can effectively maximize physician reimbursement. 

However, even if coders report services optimally, physicians will encounter problems. If you are aware of these potential problems, you will be better equipped to handle them.

Here are some examples of problems and outcomes:
1. If you bill for the preventative and diagnostic codes with appropriate modifiers, etc., and bill the patient for any deductible applied on the problem-oriented E&M code, the patient will likely call to complain, stating there should be no out of pocket because the reason for the visit was preventative.  Since most patients currently have little to no comprehension of the intricacies and protocols of correct medical coding, it will be difficult to explain why the visit was billed the way it was, and the patient will most likely refuse to pay and take his business elsewhere.
2. If you spend extra time and effort evaluating and treating a patient for all her complaints and concerns during a preventative visit, and only bill for the preventative portion of the visit, then you are saddled with the entire burden of all the newly insured, without the appropriate compensation.
3. If you bill for both the preventative and diagnostic portion of the visit, and simply waive any deductible, you may open yourself up to frequent billing audits. 

None of these scenarios is ideal, so it is important to determine which is best for you. In any case, it’s a good idea to present a brief, bullet pointed disclaimer to your patients making them aware of the different types of care and what their potential out of pocket costs might be - perhaps even a simple check box with the statement, “I do (or do not) want to receive diagnostic services not covered under my preventative benefits.”  This way there are no surprises, and you may help enhance your professional brand as a trustworthy doctor.