# Preventive labs vs diagnostic PLEASE ADVISE!!



## AR2728

Here's our situation...

We have multiple patients who have a benefit of annual exam once a year paid at 100% through their insurance.  Our patients typically want to have this performed when we would normally schedule their 6 month follow up for HTN/Hyperlipdemia-essentially getting a two for one deal.  Our doctors continue to allow this to happen and have therefore, created a nightmare for our billing department.  So, in this scenario patient comes in 2 days early for his labs--he states he is here for preventive labs, when the nurse views his chart the patient is due for his lipid and BMP for his HTN and Hyperlipidemia.  The patient also has a PSA-billed as screening.  We bill out his BMP and LIPID with his HTN and hyperlipidemia diagnosis as this is routinely done for monitoring and not as preventive--V70.0.  

The patient is now irate and yelling at me because he wants his labs billed with a V70.0 even though he has clear indication for these tests being performed and requested by the MD for his HTN hyperlipdemia.  

The only conclusion our office can think to come up with to avoid the labs being ordered due to the patients known conditions was to have the patients schedule strickly a preventive visits with labs being ordered and/or performed that same day and tied directly to that V70.0 preventive code.  As I said, the patients essentially want a two for, their 6 month followup and labs done for HTN/etc along with their preventive and all of it billed as preventive with V70.0.  

We have always stood by using their chronic diagnosis and not screening or preventive  due to the fact that it is evident in thier visit note they have a condition that the physician monitors by specific lab tests routinely.  Is it incorrect to just apply the V70.0 to labs tests even though they have a known diagnosis simply because they want it covered at 100%?  The kicker here is that their insurance company tells them that we coded it wrong, and simply need to alter the code to V70.0 and they will cover it--its that easy to them....


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## Pam Brooks

You are not alone. This is a problem everywhere.

You are doing everything correctly. It doesn't matter when the labs are drawn....what matters is why. So if the patient has diabetes, you can't code a screening glucose lab....they're already diabetic. The fact that it was drawn for the Preventive visit is irrelevant. Medical necessity plays a part in all claims we code for, and diagnosis coding rules specifically state you may not code a screening diagnosis if a symptom or disease exists. 

The physicians did not want to re-schedule patients for the diagnostic/surveillance labs, so it fell to the coding/billing department to sort this all out. 
Here's what I did: I personally addressed our payer group at a past MGMA meeting regarding this issue, and followed up with an e-mail to all of our payer reps with an explanation of correct diagnosis coding, and a synopsis of the scenario you just outlined, and that we felt that they were asking us to commit fraud when they suggested to patients that we had coded incorrectly, and that if we changed the code it would get paid. I also added that we would be telling patients that they had received erroneous information from their insurance companies, (that got their attention!), and if it continued, we'd contact the state insurance commissioner. Their excuse (because they wisely agreed we had coded correctly) was "poor customer service training". For one payer, who didn't quite get the message...I forwarded some specific examples, and asked them to investigate who the customer service person was. It wasn't long before it stopped. Additionally, our billing staff was instructed to tell the patients the truth...they already have the condition, so we can't re-screen for routine labs. I would discourage you from changing codes to pacify the patient, but it does take some finesse to explain to patients that you can't change the code.

I used to get at least three calls a day on this from the billers. I'm getting about one a month now.  Hope this helps.


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## AR2728

Thank you so much for this information.  I had reviewed previous posts and found some offices were using V70.0 as primary followed by the chronic condition/med monitoring diagnosis-which, of course, resulted in preventive coverage payment.  They stated that it was a benefit the patient had.  I still did not feel that was right.  

The patient actually brought a copy of his document regarding the preventive benefit, the first paragraph states..."Services designated as preventive care include periodic well visits, routine immun, and certain screenings for SYMPTOM-FREE or DISEASE-FREE individuals."  He inadvertantly provided the exact document stating we are correct!  Moreover, the lab diagnosis they want us to use are not v70.0 or V72.62 but the screening codes as in V77.1--which again is clearly not the case in a patient with known condition.  

I am certainly feeling much more confident in our stance after hearing from you.  I will be saving a copy of your reply!


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## mitchellde

The labs for monitoring of the drugs the patient is taking for there chronic conditions are best coded with the V58.83 for therapeutic drug monitoring and V58.6x to indicate the drug.


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## rthames052006

Pam Brooks said:


> You are not alone. This is a problem everywhere.
> 
> You are doing everything correctly. It doesn't matter when the labs are drawn....what matters is why. So if the patient has diabetes, you can't code a screening glucose lab....they're already diabetic. The fact that it was drawn for the Preventive visit is irrelevant. Medical necessity plays a part in all claims we code for, and diagnosis coding rules specifically state you may not code a screening diagnosis if a symptom or disease exists.
> 
> The physicians did not want to re-schedule patients for the diagnostic/surveillance labs, so it fell to the coding/billing department to sort this all out.
> Here's what I did: I personally addressed our payer group at a past MGMA meeting regarding this issue, and followed up with an e-mail to all of our payer reps with an explanation of correct diagnosis coding, and a synopsis of the scenario you just outlined, and that we felt that they were asking us to commit fraud when they suggested to patients that we had coded incorrectly, and that if we changed the code it would get paid. I also added that we would be telling patients that they had received erroneous information from their insurance companies, (that got their attention!), and if it continued, we'd contact the state insurance commissioner. Their excuse (because they wisely agreed we had coded correctly) was "poor customer service training". For one payer, who didn't quite get the message...I forwarded some specific examples, and asked them to investigate who the customer service person was. It wasn't long before it stopped. Additionally, our billing staff was instructed to tell the patients the truth...they already have the condition, so we can't re-screen for routine labs. I would discourage you from changing codes to pacify the patient, but it does take some finesse to explain to patients that you can't change the code.
> 
> I used to get at least three calls a day on this from the billers. I'm getting about one a month now.  Hope this helps.



I'm so glad someone else out there understands and agrees with the frustration.  I actually wrote an article for Coder's Voice addressing this issue and boy did I get hammered by a few people who didn't agree with it.  

I tried addressing this issue with one of our carriers, who told me I needed to contact that particular patients employer because it's an" employee benefit"  I called the employer and that woman who I talked to was rude, didn't listen and basically told me to commit fraud because " her doctor does".  

I was appauled at what she asked "us" as providers of service to do.  

We don't get too many calls anymore about this issue but for awhle there it was a daily thing.


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## Jacoder

This all makes sense and seems very clear, but what do facilities do when the pateint calls and says that we coded the labs wrong. All I have to go by is a paper order that says CBC, Lipid, TSH, ect. Dx: Fatigue and Obesidy. I can't see the office visit, so I don't know what the reason is for the office visit durring which the lab order was written. Almost everyone can complain of Fatigue, and being obese isn't really an "illness" or "condition". How do we confront this when we really don't know why these labs were drawn other than what the Dr tells us. Do we tell them that to call the Dr?


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## AR2728

I actually work in the physician's office who is ordering the labs, so I have access to the visit note, reason for visit, and will query the physician if necessary.  I am assuming you are the lab facility and therefore, only have the lab order.  In those cases, I would advice the patient to contact the physician who ordered the test if they have further questions.  You are simply following the order provided by the physician and are unable to provide further information nor do you have the ability to alter a diagnosis.  

We actually sat down with all our physicians at the same time and got all our staff on the same page.  Bottom line for us, if they have a documented known condition their labs are no longer done as screening or preventive.  How can we run a preventive glucose for diabetes on a diabetic patient?  This is no longer a test in which we are looking for a disease, one exists.  We still have patients informing us that we billed it incorrectly and that insurance said we just need to refile with a new code.  It's extremely frustrating and I don't forsee the issue resolving, so we will continue to inform patients on proper billing procedures and that our office will not alter coding to simply get something paid.


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## mitchellde

Once the patient is on medication for a particular disease such as insulin or lipitor or phosamax,  then then labs or diagnostic studies are being performed to monitor the effectiveness of the drugs so the provider can determine if the dosages should be adjusted or the medication changed, therefore these are for drug monitoring purposes.. V58.83 with the corresponding V58.6x code.


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## Skenyon

*Preventive vs Diagnostic labs*

This is all the insurance companies fault!  With the new Health care reform, insurance comapnies must allow its members preventive care and screenings with no cost sharing.  So in order for them to still make their HUGE profits, they now only offer large deductible plans to their members and patients are now responsible for labs and imaging services that they previously wouldn't have. They are now getting bills for services that they have always received and never been billed.  It's happening everywhere.  We get calls all day long about the bills their receiving. The most popular one is this one about "preventive screening labs".  I love it when the insurance company reps tell the patients, that we are coding incorrectly! 

The rule has always been this:  Screening tests are defined as done/ordered in the course of an annual physical examinatin or as part of a routine physical check-up, WITHOUT SIGNS, SYMPTOMS OR THE PRESENCE OF AN ILLNESS.

I actually have to explain this to the insurance company reps!  I asked one of the large plans for written documentation on this, and she said to me, it's not up to them to tell us how to code!

Never a dull moment in healthcare billing and coding!


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## rthames052006

AR2728 said:


> I actually work in the physician's office who is ordering the labs, so I have access to the visit note, reason for visit, and will query the physician if necessary.  I am assuming you are the lab facility and therefore, only have the lab order.  In those cases, I would advice the patient to contact the physician who ordered the test if they have further questions.  You are simply following the order provided by the physician and are unable to provide further information nor do you have the ability to alter a diagnosis.
> 
> We actually sat down with all our physicians at the same time and got all our staff on the same page.  Bottom line for us, if they have a documented known condition their labs are no longer done as screening or preventive.  How can we run a preventive glucose for diabetes on a diabetic patient?  This is no longer a test in which we are looking for a disease, one exists.  We still have patients informing us that we billed it incorrectly and that insurance said we just need to refile with a new code.  It's extremely frustrating and I don't forsee the issue resolving, so we will continue to inform patients on proper billing procedures and that our office will not alter coding to simply get something paid.



OMG.... Thank you so much!  I've been preaching this for so long, even wrote a short article for Coder's Voice a few months ago and got ripped by quite a few coders/billers who still feel that " if the insurance company pays for a screening we should bill it as a screening".  I believe that is fraudulent and incorrect coding, we should not be coding to "get a claim paid" but coding based on necessity.

My chapter hosted a seminar last year and we had a local insurance carrier's Medical Director speaking and I asked him about this and his response was:

"how do you do a screening on someone with known disease"?  I thought finally, someone who gets it within the carrier world!  

We still get angry, upset, irrate patient calls because their insurance tells them " they are allowed a screening"  I say since these carriers act as if they are doing such a great thing, then they should be paying based on the cpt code and not the diagnosis, since you want to pay for a screening!  It shouldn't matter what the dx code is in that case, they could say ok CPT code 80061 is coming thru on this patient, he/she hasn't had this test done in over a year, "process for payment" but they want the providers to commit fraud and say V70.0 or whatever corrolating dx code they want us to use.  

Thanks for all the brilliant comments on this thread.....hopefully the message will get thru one of these days....


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## Pam Brooks

Skenyon said:


> This is all the insurance companies fault! With the new Health care reform, insurance comapnies must allow its members preventive care and screenings with no cost sharing. So in order for them to still make their HUGE profits, they now only offer large deductible plans to their members and patients are now responsible for labs and imaging services that they previously wouldn't have. They are now getting bills for services that they have always received and never been billed. It's happening everywhere. We get calls all day long about the bills their receiving. The most popular one is this one about "preventive screening labs". I love it when the insurance company reps tell the patients, that we are coding incorrectly!
> 
> The rule has always been this: Screening tests are defined as done/ordered in the course of an annual physical examinatin or as part of a routine physical check-up, WITHOUT SIGNS, SYMPTOMS OR THE PRESENCE OF AN ILLNESS.
> 
> I actually have to explain this to the insurance company reps! I asked one of the large plans for written documentation on this, and she said to me, it's not up to them to tell us how to code!
> 
> Never a dull moment in healthcare billing and coding!


 
I agree to a point, and have tackled our local payers with regard to their "you've coded it wrong" message. That, I'm happy to report, has all but evaporated from our radar, and patients are beginning to understand the concept of compliance from our perspective. However, insurance companies are doing exactly what our government required (and our nation needs) .....paying 100% for preventive care. Up until ACA, preventive services weren't typically covered at all, except for a well-exam and an annual pap. Now they're virtually all paid at 100% provided you're symptom free...which is what preventive care is. There's the catch!! How many Americans can say they are healthy and symptom free? Not too darn many, and that is why they're ticked off at our billers when we deliver the message that they can't receive 'preventive care' because they're already symptomatic?  
Americans hear "free health care" and think that they are entitled...even though they already have diseases and symptoms that we cannot possibly re-screen for. Some health plans have even gone so far as to document this in their coverage limitations, which is helpful only if you read your policy. 

While it is impossible to prevent diseases you already have... some preventible diseases (hypertension, hyperlipidemia, diabetes, obesity) can be reversed with proper self-care. And by getting these numbers under control, Americans can reduce their overall healthcare expenditures. The ACA is finally forcing Americans to take a good hard look at their unhealthy selves, and attempting to make some changes to our overburdened system by rewarding the healthy instead of rewarding the sick like we've been doing.  About time, I say.  As a healthcare consumer and an employee with an employer-sponsored health plan, I'm a tad indignant that my premiums increase year after year, while I watch my co-workers continue to smoke, eat junk at their desks, and refuse to exercise. I sympathize....to a point. But let's place at least some of the blame where it belongs.


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## genjer712

I agree and disagree with a lot of the points made. First of all, I work for an insurance company and have for several years. I am almost offended by the comment" it is all the insurance companies fault". For the majority of the plans, preventive care is paid at 100%. But it is for truely "preventive care". If you already have diabetes, what are you preventing? We process claims based on how claims are received. We look at the pointers that are used for each lab/service billed. Working in customer service, we get calls all day long saying we processed the claims wrong. Our response, "we process the claims on how the claims are received". If the pointer used is for a medical DX, then "yes", we apply the lab/service to the appropriate level of benefits such as deductible/coinsurance. If it states "routine", we process at 100%. We offer to outreach to the provider to confirm if correct DX is used. Most of the time the response we get is "yes the patient was here for routine exam, however we discussed his underlying medical issues as well. Therefore, billed the medical DX". Patients do not understand this. They "assume" since they are going for their routine exam, it should all be covered in full. 

On a personal note....my own doctor has a memo in each treating room that states if they discuss anything other than routine matters during the routine exam, they will also bill for a problem focused exam. Or they want you to schedule a separate exam to discuss the “other issues”. Again, patients are not advised of this when going in for their own routine exams.

Everyone is quick to point a finger at the insurance company that the plans offered to the companies are all high deductible plans. When in reality, the employers are choosing their own plans. It is cheaper for the employer to choose a high deductible health plan (HDHP) and put more of the cost on the employee. Insurance companies still have copay plans and HMO plans, but they are very costly to the employers. Employers cannot afford it. Therefore they lower their cost by choosing a HDHP and putting more of the cost on their employees.

This is just my 2 cents...hope no one takes offense!

Gena


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## Pam Brooks

genjer712 said:


> I agree and disagree with a lot of the points made. First of all, I work for an insurance company and have for several years. I am almost offended by the comment" it is all the insurance companies fault". For the majority of the plans, preventive care is paid at 100%. But it is for truely "preventive care". If you already have diabetes, what are you preventing? We process claims based on how claims are received. We look at the pointers that are used for each lab/service billed. Working in customer service, we get calls all day long saying we processed the claims wrong. Our response, "we process the claims on how the claims are received". If the pointer used is for a medical DX, then "yes", we apply the lab/service to the appropriate level of benefits such as deductible/coinsurance. If it states "routine", we process at 100%. We offer to outreach to the provider to confirm if correct DX is used. Most of the time the response we get is "yes the patient was here for routine exam, however we discussed his underlying medical issues as well. Therefore, billed the medical DX". Patients do not understand this. They "assume" since they are going for their routine exam, it should all be covered in full.
> 
> On a personal note....my own doctor has a memo in each treating room that states if they discuss anything other than routine matters during the routine exam, they will also bill for a problem focused exam. Or they want you to schedule a separate exam to discuss the “other issues”. Again, patients are not advised of this when going in for their own routine exams.
> 
> Everyone is quick to point a finger at the insurance company that the plans offered to the companies are all high deductible plans. When in reality, the employers are choosing their own plans. It is cheaper for the employer to choose a high deductible health plan (HDHP) and put more of the cost on the employee. Insurance companies still have copay plans and HMO plans, but they are very costly to the employers. Employers cannot afford it. Therefore they lower their cost by choosing a HDHP and putting more of the cost on their employees.
> 
> This is just my 2 cents...hope no one takes offense!
> 
> Gena


 

Gena, none taken, and great post.   What we hear from patients is that the insurance representatives are blatantly telling them that we coded these incorrectly.  That's the part that's frustrating!  If only all insurance company employees were as knowledgable as you!  I've found it helpful to work directly with our provider representatives.  Establishing good working relationships with these individuals makes coders' lives easier, and I'd encourage everyone to do the same. 

Have a good weekend, all.


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## Cary

Can someone please tell me when do you use V70.0 vs V72.62 ?  I was under the impression that V70.0 was to be used for preventative wellness visits where this was the only dx. or to cover tests done at a yearly exam that did NOT have a dx attached to a specific test.  If the patient is being seen for an annual exam will labs be covered for preventative with the V72.62 dx ?


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