from the united healthcare web site
Preventive vs. Diagnostic Services:
Certain services can be done for preventive or diagnostic reasons. When a service is performed for
the purpose of preventive screening and is appropriately reported, it will be adjudicated under the
Preventive Care Services benefit.
Preventive services are those performed on a person who:
1. has not had the preventive screening done before and does not have symptoms or other
abnormal studies suggesting abnormalities; or
2. has had screening done within the recommended interval with the findings considered normal;
or
Preventive Care Services
Page 4 of 30
Coverage Determination Guideline
Confidential and Proprietary, © UnitedHealthcare, Inc. 2011
3. has had diagnostic services results that were normal after which the physician
recommendation would be for future preventive screening studies using the preventive
services intervals.
4. has a preventive service done that results in a therapeutic service done at the same encounter
and as an integral part of the preventive service (e.g. polyp removal during a preventive
colonoscopy), the therapeutic service would still be considered a preventive service.
Examples include, but are not limited to:
A woman had an abnormal finding on a preventive screening mammography and the
follow up study was found to be normal, and the patient was returned to normal
mammography screening protocol, then future mammography would be considered
preventive.
If a polyp is encountered during preventive screening colonoscopy, the colonoscopy,
removal of the polyp, and associated facility, lab and anesthesia fees done at the same
encounter are covered under the Preventive Care Services benefit.
When a service is done for diagnostic purposes it will be adjudicated under the applicable nonpreventive
medical benefit.
Diagnostic services are done on a person who:
1. had abnormalities found on previous preventive or diagnostic studies that require further
diagnostic studies; or
2. had abnormalities found on previous preventive or diagnostic studies that would recommend a
repeat of the same studies within shortened time intervals from the recommended preventive
screening time intervals; or
3. had a symptom(s) that required further diagnosis.
Examples include, but are not limited to:
A patient had a polyp found and removed at a prior preventive screening colonoscopy. All
future colonoscopies are considered diagnostic because the time intervals between future
colonoscopies would be shortened.
A patient had an elevated cholesterol on prior preventive screening. Once the diagnosis
has been made, further testing is considered diagnostic rather than preventive. This is true
whether or not the patient is receiving treatment.
If a Preventive service results in a therapeutic service at a later point in time, the
Preventive Service would be adjudicated under the Preventive Care Services benefit and
the therapeutic service would be adjudicated under the applicable non-preventive medical
benefit.
Related Services:
Services that are directly related to the performance of a preventive service are adjudicated under the
Preventive Care Services benefit. . For example, all services for a preventive colonoscopy (e.g.
associated facility, anesthesia, pathologist, and physician fees) are adjudicated under the Preventive
Care Services benefit. Note, however, that benefit adjudication is contingent upon accurate claims
submission by the provider, including diagnosis, procedure, age and gender.
Preventive vs. Diagnostic Services:
Certain services can be done for preventive or diagnostic reasons. When a service is performed for
the purpose of preventive screening and is appropriately reported, it will be adjudicated under the
Preventive Care Services benefit.
Preventive services are those performed on a person who:
1. has not had the preventive screening done before and does not have symptoms or other
abnormal studies suggesting abnormalities; or
2. has had screening done within the recommended interval with the findings considered normal;
or
Preventive Care Services
Page 4 of 30
Coverage Determination Guideline
Confidential and Proprietary, © UnitedHealthcare, Inc. 2011
3. has had diagnostic services results that were normal after which the physician
recommendation would be for future preventive screening studies using the preventive
services intervals.
4. has a preventive service done that results in a therapeutic service done at the same encounter
and as an integral part of the preventive service (e.g. polyp removal during a preventive
colonoscopy), the therapeutic service would still be considered a preventive service.
Examples include, but are not limited to:
A woman had an abnormal finding on a preventive screening mammography and the
follow up study was found to be normal, and the patient was returned to normal
mammography screening protocol, then future mammography would be considered
preventive.
If a polyp is encountered during preventive screening colonoscopy, the colonoscopy,
removal of the polyp, and associated facility, lab and anesthesia fees done at the same
encounter are covered under the Preventive Care Services benefit.
When a service is done for diagnostic purposes it will be adjudicated under the applicable nonpreventive
medical benefit.
Diagnostic services are done on a person who:
1. had abnormalities found on previous preventive or diagnostic studies that require further
diagnostic studies; or
2. had abnormalities found on previous preventive or diagnostic studies that would recommend a
repeat of the same studies within shortened time intervals from the recommended preventive
screening time intervals; or
3. had a symptom(s) that required further diagnosis.
Examples include, but are not limited to:
A patient had a polyp found and removed at a prior preventive screening colonoscopy. All
future colonoscopies are considered diagnostic because the time intervals between future
colonoscopies would be shortened.
A patient had an elevated cholesterol on prior preventive screening. Once the diagnosis
has been made, further testing is considered diagnostic rather than preventive. This is true
whether or not the patient is receiving treatment.
If a Preventive service results in a therapeutic service at a later point in time, the
Preventive Service would be adjudicated under the Preventive Care Services benefit and
the therapeutic service would be adjudicated under the applicable non-preventive medical
benefit.
Related Services:
Services that are directly related to the performance of a preventive service are adjudicated under the
Preventive Care Services benefit. . For example, all services for a preventive colonoscopy (e.g.
associated facility, anesthesia, pathologist, and physician fees) are adjudicated under the Preventive
Care Services benefit. Note, however, that benefit adjudication is contingent upon accurate claims
submission by the provider, including diagnosis, procedure, age and gender.