Not surprisingly, compared to the ICD-9 code set, the ICD-10 code set, applicable to preventive services, is greatly expanded and providers need to be certain they are using the code(s) payers want to see on claims for preventive services. CMS has identified, for its covered preventive services, not only the required CPT and/or HCPCS level II codes but also the required ICD-10 diagnosis codes. I have provided a link to CMS’s Preventive Services Chart below for convenience. This quick reference identifies, per covered preventive service type, the required coding.
Some commercial payers have also published their coding requirements for covered preventive services. United Health Plan’s guidance for commercial policies is also linked below because it is quite specific and comprehensive. Anthem BC/BS commercial policies are specific to each state and identify codes “for informational purposes only” and so are less helpful in terms of claim submission guidance. That makes tracking preventive service claims to Anthem from submission to payment or denial extremely important. Providers should identify and research coding requirements for any payers with whom they are directly contracted.
Preventive services impact many medical specialties including, but not limited to, family medicine, internal medicine, pediatrics, radiology, gastroenterology, lab/pathology. The negative impact to providers who don’t submit preventive services claims appropriately is considerable. The negative impact to patients for whom claims are not submitted appropriately is considerable as well. Copays, coinsurance and deductibles may all be affected, depending on a patient’s plan coverage, and providers need to be certain to submit claims appropriately so that preventive claims are paid from the correct coverage “bucket”.
Much is asked of providers today and we cannot also expect them to know and code to each payer’s requirements for preventive services. Even the Medicare population’s coding requirements are not consistent given that this population’s coverage may include straight Medicare or any number of commercially administered Medicare advantage plans. For this reason it is imperative that qualified coders review and code all preventive (or potentially preventive services) and then provide education on documentation requirements to providers. Generally, providers should be directed to document to the most stringent guidelines known so that, no matter the plan, documentation is compliant.
Provider practices should analyze preventive services data to determine the impact these services have on their revenue cycle and then put the proper processes and people in place to optimize efficiency, compliance and bottom line.