Screening and Diagnostic Services - JE Part B

Screening services are those services used to detect an undiagnosed disease where early detection may prevent harm and where the patient has no signs, symptoms, laboratory evidence, radiological evidence or personal history of the disease. Examples include screening for:

• Patient testing for a disease due to family history.
• Preoperative patient testing for an undiagnosed disease that may increase operative risk, when done in the absence of signs, symptoms, abnormal laboratory or radiological findings.

Diagnostic services are those used to manage a diagnosed disease. Examples of diagnostic services include:

• Tests that evaluate symptoms, signs and abnormal laboratory or radiological findings in order to make a diagnosis.
• Patient testing for an infectious disease when there has been a recent and significant exposure to that disease, even though the patient has no symptoms or signs of the disease.

Note: While both diagnostic and screening services may be appropriate, in most instances, screening services are not covered by Medicare.

Screening Services Becoming Diagnostic Services

A procedure that begins as a screening service but uncovers significant pathology that requires attention at that time, becomes a diagnostic procedure. An example is a screening colonoscopy where the physician finds a polyp. In this instance, a significant symptom elicited on a system review or an abnormal physical finding discovered during what began as a routine annual screening examination, changes that evaluation and management encounter to a diagnostic exam.

In contrast, a test that began as screening service remains a screening service even though it is reported some time later as abnormal. An example is a screening x-ray or screening lab test where diagnostic findings are reported to the physician several days after the test.

Advance Beneficiary Notice of Noncoverage (ABN) Use

When a service is provided and the individual patient's diagnosis is not approved for a specific service based upon a Local Coverage Determination (LCD) or National Coverage Determination (NCD) or if the service is considered investigational, the service may be denied for medical necessity. In this instance the physician or supplier should obtain an ABN from the beneficiary prior to the service.

The claim should be filed with a GA modifier and if the service is denied it will be denied as patient responsibility. If the ABN is not obtained and the claim is filed (should be filed with a GZ modifier), the claim will be denied as provider liability/contractual obligation and may not be billed to the beneficiary or their secondary insurance. The ABN should be filled out at the doctor's office and a copy sent with orders for any tests - especially when only a specimen is being sent to the laboratory.

If a service is provided for screening purposes, the claim should be filed with a screening diagnosis. The claim will be denied as non-covered by statutory exclusion as patient responsibility. The provider or supplier should advise the patient that the service is non-covered and provide the ABN. The claim should be filed with the GY modifier (statutorily excluded) and will deny as patient responsibility.