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Preventive Visits

Preventive Visits vs Office (Evaluation and Management) Visits

Preventive Visit

Preventive visits are an important part of your healthcare. Preventive visits are unique in that they are dedicated to discussing your overall health with your physician and to discuss best practices for your ongoing wellness. During a visit, you might receive a complete physical exam, have samples taken for annual screenings (blood glucose, cholesterol, CBC, CMP).

This visit can also include lifestyle counseling, including discussions on overall diet, exercise and wellness ideas.

It may also include testing such as pelvic exams, Pap smears, ordering of prostate and colorectal cancer screenings and counseling on topics like sexually-transmitted diseases, obesity or tobacco use.

This is also a great time for our physicians to just hear about what is going on in your life to see if there are any red flags that may contribute to declines in your overall wellness. Your health goals are also discussed so that you and your physician are in agreement of how you want to be the healthiest you!

Your physician may also decide to refill an existing prescription based on the discussion.

The important thing to remember is that these visits are typically when you are asymptomatic or to discuss concerns outside of any current symptoms. In other words, you are not coming in discussing an acute concern such as illness, pain, or active or recurring symptoms.

Preventive – wellness vs illness

Office Visit

Office visits, also known as Evaluation and Management or E&M, are focused on discussing one or more specific health concerns.

If the main reason for the appointment, or the main discussion in the appointment is any illness or injury then it would be an E&M office visit. This includes managing acute concerns, like body pain, colds, active allergy symptoms, etc. This also includes managing chronic concerns like diabetes, GI issues, hypertension, allergies, etc.

Another example of how an office visit differs from a preventive visit is if you and your physician decide to change an existing prescription to a different dose or Rx. This differs from a preventive visit where Rx discussion would generally be a refill of an existing prescription.

Just like preventive visits, these are critical to managing your health care. It is always important to seek and receive medical care if you are managing acute or chronic health concerns.

Why does it matter?

Spoiler Alert: Insurance

You might be thinking, "Thanks for the information, but why do I care as long as I get the care I need?"

The answer is your insurance coverage. Due to the Affordable Care Act, most insurance is required to cover your Annual Preventive appointment at no cost to you. That is a great benefit, but it is often misunderstood by patients.

Sometimes patients see the option for a free Preventive visit and think that means they get one free office visit per year. That is incorrect.

The Preventive Visit must fit insurance guidelines in order to qualify as a fully covered and paid visit. Once the visit get's into the area of Evaluation and Management, your physician has a legal and ethical obligation to bill it appropriately.

At Specialty Natural Medicine, your physician's primary concern is getting you the medical care you need. If you bring up a concern that requires medical consultation, they are going to take steps to address it for your best and highest health and wellness.

Balance – what to bill – preventive or e and m

What should I do?

So how do you balance the desire to receive your Preventive visit with no financial liability and your Doctor's desire to put your health and wellness at the forefront?

Simply put, let us know. It's that simple.

When you book your appointment, please let us know that you are looking for it to be your Annual Preventive. As your Doctor makes the final decision on how to code the appointment, it is also best to remind them at the beginning of the appointment that you are there for your Annual Preventive visit.

We will make a note if it on your appointment and your physician will work with you to keep the discussion within the boundaries of a Preventive visit.

If an acute concern or "chief complaint" comes up, your Doctor can discuss whether you wish to discuss at the current appointment or schedule a future appointment to discuss. If you and your Doctor decide to explore, the appointment will be billed appropriately based on the scope and content of the visit.

Frequently Asked Questions

Medical procedures and services are billed to insurance using Current Procedural Terminology (CPT) codes. These codes inform the insurance company which service or services was delivered.

Along with CPT codes, physicians provide ICD-10 diagnosis codes (Dx codes).

The combination of CPT and Dx codes together make up a claim and determine whether a procedure is approved or denied. Chart notes are not required to be submitted with a claim, but are part of the overall claim and can be requested at any time by insurance payors.

This is important to understand since there are special CPT and Dx codes for Preventive visits. If an acute or chronic condition is discussed, managed or treated at a Preventive visit then the Doctor needs to make that Dx code part of the claim. The presence of an acute or chronic Dx as part of a Preventive visit will result in denial of the claim.

Likewise, if the chart notes indicate a Dx code should have been submitted than the insurance company can retroactively deny a paid claim making the patient liable for the entire billed amount.

Please note that it would be insurance fraud for a Doctor to knowingly misrepresent a provided service, or for a patient to ask us to provide false information to insurance.

Your Annual Preventive visit is a special time dedicated to discuss wellness and prevention. Preventive visits should be agreed upon ahead of time to make sure you get the full value of these appointments.

Misrepresenting an E&M visit as Preventive would be a violation of contractual agreements and subject you and the Doctor to serious legal and/or financial consequences.

There are a few reasons why this is not optimal. Unless your Doctor knows before they start consulting with you that you want a Preventive visit, the discussion will likely end up being about an acute or chronic health condition. Those cannot be billed as Preventive.

Next, you do not want a visit billed as Preventive unless you request it. Why? Because you generally only get one covered general Preventive visit per year.

Insurances generally will decline any billed Preventive visits beyond the yearly limit. Denied claims can result in fees up to the full price that a clinic bills to insurance.

The short answer is no.

If you are experiencing or concerned about symptoms related to an acute or chronic health condition, the visit will almost certainly meet the definition of an E&M office visit.

You are always free to request a Preventive visit, but the Doctor cannot treat your immediate concern and bill the visit as a Preventive visit.