Wiki Query Providers

Good afternoon, I am in need on some opinions.. With the services you provide to other facilities.. I have a question about labs that patient have completed during their annual wellness visits during/not during the same time as Medication renewal visits..

Patient 1-Meritain Health - said she was told to have her labs done prior to appointment for her wellness visit… on 12/11/25-- then had her wellness visit on 12/15/25--- Provider used E66.9, F41.9 and G47.10 and did not have Z00.00 listed on the patient lab order--- So her labs were not covered at all for -"Charges ineligible based on the exclusions outlined in your benefit plan."-- Insurance states non covered diagnoses, as her insurance only covered Panel, Lipid, TSH and A1C under her yearly wellness checkup..

Patient 2- Commercial Plan--- Her visit and labs were done same day, she went in for a wellness and pap with wellness labs to be completed-- No active issues except for Benign neoplasm of pituitary gland, which endo provider runs her prolactin level check every 5 years.. But provider ordered labs with that diagnoses only- no wellness diagnoses which was reason for visit… The lab claim was applied to patient deductible and she is upset as she was seen for her annual wellness visit and sees a specialist for her other issue.
----- How would someone handle this??

We get calls from patient all the time upset as when they get a bill, and we tell them that per the orders from provider we billed per the order-- some would even call their insurance- and then call us back and state we billed it wrong as it was a part of their wellness. Per call with their insurance, they stated that the correct code should have been Z00.00 primary to other diagnosis..
We have had some insurances like BCBS and UHC state the same to us as Wellness labs are apart of their covered services.. And per their representatives- orders should be stated as Z00.00 primary, then diagnoses fir the labs.
We were told and must tell all patients and insurances companies- that we must bill services how the provider orders them and we can not change anything after the lab is completed and services are billed… Even if we get a denial for a non-covered diagnoses for a lab or ect.

I am not sure how to handle this as another facilities state-- No you cannot do anything and either take the write of or drop to patient resp per insurance remit-
and some state- Yes you can query, lets say its a non covered Diagnoses - but they choose a diagnoses for a lab that is not covered, but per the patient Active Medical Problem List there is an active Diagnoses that is coverable for that lab the provider ordered, just the provider just choses any diagnoses or choses a single diagnoses for all labs.....

I hope this make a little since, but I have worked at both facilities types and now i am not sure what is correct........

Thank you for your knowledge.

Since the ACA in 2009, and the mandate to provide screening services at no cost-share to patients, this issue has been a real PITA. (sorry ..... but I call 'em like I see 'em). That the insurance companies tell patients that this was coded wrong is a reason for you to reach out to your provider services representatives and complain. I've done this through MGMA, and had some pretty good success. They know better, but they do it anyway.

Having labs drawn in preparation for an annual well exam does not necessarily mean that the labs are also screening or preventive in nature. If labs are ordered and drawn relative to conditions that the patients already have (surveillance labs), we cannot screen for a condition that is already in existence.

Providers do need a bit of education on this, but I generally find that if the patient is diabetic, needs an A1C, and is scheduled for a Pe, then a DM diagnosis is definitely appropriate, and that's usually what the provider orders. We have gone so far as to put signage in our offices to remind patients that although they may be scheduled for a preventive exam, lab work may be ordered to keep track of their current chronic conditions, and that they may have financial responsibility for those labs. I generally find that the diagnosis for the condition is rarely incorrect..... it's more likely that providers will use the Z00.00 when they really shouldn't, but of course we never get patient calls when the claim is covered in full! You can give the patient the courtesy of checking their problem list to see if a Dx makes sense, but then you have to indicate that the order is updated if you need to make a change.
What I never recommend is to re-code the labs with a preventive diagnosis to make the patient happy. That's sliding way too close to the F-word. Train your billers and AR people to have those patient discussions..... we used to have our billers ask the patient......"It looks like you're diabetic. It appears the doctor ordered lab work to check to see if your diabetes is controlled. Are you diabetic?" The patient is going to say 'yes', and that's when you explain that lab work for chronic conditions is not preventive....they already have the disease. If the patient asks you to re-code a surveillance lab as a preventive lab simply to get paid, let the patient know that you are sorry but you will not commit fraud on their behalf. Seems like a no-brainer, but many patients think that the visit type and not the lab work is how the lab claim should be paid, and overall, they have no idea how insurance works.