The most common insurance claim denials are due to inaccurate frequency of these services being billed, the services being provided within an invalid place of service, or the lack of a payable diagnosis being present on the claim.
Concerning frequency of the preventive services, many are only covered annually. The most obvious of these is the annual wellness visit. However, others like the depression screening are only covered annually as well. To enable your office to have the most information on file and not provide services unnecessarily or for free, it is best to try and obtain a good patient history concerning preventive services.
For new patients, it is highly recommended that you make sure another provider has not already provided the preventive service for your patient by discussing with the patient themselves as well as checking the patient’s eligibility and benefits for coverage. Online sites for Medicare typically provide the patient’s history of preventive services for the patient. If billed more than once within the year or outside of its allowed time frame, your services will be denied by insurance due to maximum benefits reached.
There are some exceptions. The tobacco counseling services are covered up to 8 sessions per year. Obesity preventive services such as Intensive Behavioral Therapy (IBT) are covered more than once but must follow a specific guideline to follow within the first 6 months.
For more information, CMS provides a very easy to follow, quick reference chart at the following link:
Medicare also provides a check list that will track the preventive service, date and notations for patients to help remind your patients when it is time to return. This can enable your office to keep track with greater ease as well. You can print a copy from the link here:
You may not have known, but preventive services are only covered within a primary care setting. They will not be considered payable services when provided anywhere and everywhere. Primary care settings are those where clinicians are available to assist a patient for the majority of their healthcare. Check ahead of time for exemptions to places of service you are unsure of. Per CMS, emergency departments, inpatient hospital settings, ambulatory surgical centers, independent diagnostic testing facilities, skilled nursing facilities, inpatient rehabilitation facilities, and hospices do not qualify as primary care settings.
Finally, many LCD and even NCD policies require patients to qualify for a specific diagnosis in order to be considered appropriate for preventive services. Other policies require the actual screening diagnosis be provided on the insurance claim. For example, diabetes screenings require the diagnosis Z13.1, an encounter for the screening of diabetes mellitus. When billing for tobacco counseling, Medicare requires the patient to meet a specific diagnosis out of a group that are considered qualifying for this counseling service; there are a number to choose from.
On another note, not all insurances follow Medicare’s guidelines. For example, UHC commercial policies stipulate the BMI diagnosis is required just as Medicare; however, UHC states the BMI diagnosis must be secondarily present on the insurance claim compared to Medicare who requires the BMI diagnosis be primary on the claim. If a patient has insurance outside of Medicare and/or Medicare replacement policies, be sure to check on their policies’ corresponding requirements if you find yourself receiving claim denials.
Medicare patient responsibility involving coinsurances and deductibles are waived for preventive services. If a preventive service is provided and billed with a non-covered diagnosis, in a non-covered place of service, or too often, you are providing a free service as the patient cannot be billed!