Addressing Noncovered Services With Your Patients

Betsy Nicoletti, MS

Disclosures

March 25, 2019

In This Article

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Diagnosis Codes for Peripheral Artery Disease

Question: Our primary care practice wants to refer patients for peripheral artery disease (PAD) screening. What diagnosis codes can we use when patients are asymptomatic but have multiple risk factors?

Answer: Medicare and private insurance companies are required to pay for screening that has an A or B rating from the US Preventive Services Task Force (USPSTF).

The USPSTF assigns each of its recommendations a letter grade (A, B, C, or D) or issues an I statement, based on the certainty of the evidence and on the balance of benefits and harms of the preventive service as displayed in the recommendation grid below[1]:

USPSTF Grade/Statement Definition
Grade A The USPSTF recommends the service. There is high certainty that the net benefit is substantial.
Grade B The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.
Grade C The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small.
I Statement The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

The USPSTF gives screening asymptomatic patients for PAD an I statement: "current evidence is insufficient to assess the balance of benefits and harms of the service."

With an I rating, payers are not required, and in all likelihood will not pay for screening for PAD in an asymptomatic patient, regardless of other risk factors. Current recommendations are summarized in this Medscape article.

There are ICD-10-CM codes for screening in category Z13. The code for screening for cardiovascular disorders is Z13.6. This code, however, is not considered a covered indication for the test and probably will result in a denial, depending on payer guidelines. If the physician recommends it and the patient agrees with having the screening, obtain an Advance Beneficiary Notice (ABN) or waiver for private payers, informing the patient that it is or may be considered a noncovered service and the patient will be financially responsible for paying for the test.

There are other screenings that physicians feel are reasonable and medically necessary that do not have an A or B rating from the USPSTF. In these cases, the process is the same. Inform the patient that the service probably will not be covered, and if the patient wishes to proceed, obtain an ABN or waiver of liability acknowledging that the patient will need to pay for the service.

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