Prevention of Patient Complaints and Payer Denials: Covered vs Non-Covered Preventive Services
Written by: Pam Vanderbilt
“I just got a bill for my free annual visit!!
Sound familiar? Calls from patients who are upset because they got a bill for services they thought were covered. When I research these complaints, the issue causing the services to be processed by the payer with patient responsibility doesn’t often vary much. The most common reason is that during the visit, the provider also evaluated and managed a problem (billed an E&M with modifier 25).
The second most common reason is how the services were coded by the practice. Payer policy will indicate how preventive services should be coded to include CPT/HCPCS, correct ICD-10-CM linkage, and modifier use.
The third most common reason we see is driven mostly by how different providers approach prevention in their patient population. Some primary care providers believe it is important for patients to have annual screening labs that are not covered by payers (i.e. thyroid issues, vitamin deficiencies). Payer policies about what they will pay don’t limit our providers’ clinical judgement about what services a patient should have, just who is responsible for the bill.
All these issues can be addressed with some good policies in place combined with a little education for everyone, providers, staff and patients alike. Auditors to the rescue. We will address each thing we need to look for when auditing preventive services and determining if they are covered or non-covered, but the very first thing we need to know is:
“Was the patient symptomatic or asymptomatic?”
This question sets the stage for everything that follows—coding, coverage, patient cost-sharing, and audit risk. It is truly the question that answers whether the services is even a preventive service.
- Symptomatic vs. Preventive
- Preventive (asymptomatic): The annual wellness visit, annual depression screen, routine lipid panel, PSA in otherwise healthy men, Pap tests, screening colonoscopies—all healthy folks just checking in. The patient is not presenting with symptoms (or chronic conditions) prompting the service.
- Diagnostic (symptomatic): That colonoscopy for GI bleeding, PSA because of urinary symptoms, Pap follow-up for abnormal cells, lipid panel for patients with hyperlipidemia.
Only Z00–Z13 ICD-10-CM codes can be used when a patient is truly asymptomatic—e.g., Z13.220 for lipid disorders screening or Z12.5 for prostate neoplasm screening. If you see any other code, you’re in diagnostic territory (NOT preventive), and patient cost-sharing applies.
- Medicare vs. Commercial Payers: Two Different Playbooks
Think of Medicare and commercial payers as two referees with slightly different whistles:
- Medicare Part B uses HCPCS G-codes for most preventive service, zero dollars to the patient if billed according to the Medicare Preventive Services tool.
- Commercial (ACA-compliant) plans must cover all USPSTF Grade A & B services with no cost-sharing, but they use CPT® codes along with screening diagnosis codes and preventive modifier 33.
Always double-check plan documents—some commercial plans layer on extra wellness benefits or tweak frequency limits.
- USPSTF Grades A & B: Your Guide to Coverage
The U.S. Preventive Services Task Force grades services from A (must cover; high certainty of benefit) to D (discouraged). For 2025, key must-covers include:
- Colorectal cancer screening (ages 45–75; Grade A)
- Breast cancer screening (women 40–74; Grade B)
- Cervical cancer (Pap/HPV; Grade A)
- Depression screening (all adults; Grade B)
- Lipid disorders (ages 40–75; Grade B)
If it’s Grade A or B, payers are required to cover the service with $0 patient responsibility. Anything else? Read the fine print. Remember those PCPs who order labs for detection of vitamin deficiencies? This is grading system is why these are typically not covered screening services by payers.
| 4. Codes, Modifiers & ICD-10-CM for Preventive Services Service | Medicare | Commercial CPT® (+Mod 33) | ICD-10-CM Screening Code | Frequency |
| Welcome to Medicare (IPPE) | G0402 | N/A | Z00.00 | Once in first 12 mo |
| Annual Wellness Visit | G0438 (initial), G0439 (subsequent) | N/A | Z00.00 | 12 mo intervals |
| Depression Screening | G0444 | 96127 | Z13.30 | Annual |
| PSA Screening | G0103 | 84153 | Z12.5 | Annual (men over 50) |
| Pap + HPV Collection | G0101 (pelvic), Q0091 (Pap collection) | 99384–87 or 99394-97 | Z04.419, Z12.4 | Every 2 yrs unless high risk |
| Lipid Panel | 80061 | 80061 | Z13.220 | Every 5 yrs or per risk |
| Screening Colonoscopy | G0121 (avg risk), G0105 (high risk) | 45378 | Z12.11 | 10 yrs avg risk; 2 yr high risk; add PT if converted to diagnostic |
Don’t forget—preventive services need auditing too.
They may seem straightforward, but coding missteps and payer policy gaps can lead to costly errors.
Have you audited your preventive services lately?
Start now to protect compliance and patient trust.
About the Author: Pam Vanderbilt
As the CEO of Knowledge Tree RCM, Pam leads a team in providing compliant revenue cycle consulting services to provider owned practices.
