Understanding Preventive Services

At the spring provider seminars, questions were raised about the nature of preventive services and what makes them different from routine services. This article offers some clarification about preventive services.

Preventive care is diagnostic and includes medical procedures not directly related to a specific illness, injury, or definitive set of symptoms or obstetrical care, but rather performed as periodic health screening, health assessment, or health maintenance visits. Certain services may be provided during acute and chronic care visits or during preventive care visits for asymptomatic individuals to maintain and promote good health.

Clinical preventive services include immunizations, periodic screening examinations, well-child care for children up to 6 years old, and other disease prevention examinations. These examinations can include: cancer, cardiovascular, hearing, vision, infectious disease and well-woman screening; immunizations; and parent/patient education.

Coverage for clinical preventive services varies, depending on whether a beneficiary is using TRICARE Prime, Standard, or Extra. Providers should also be aware that there are limitations on the frequency of preventive services by type of service.

Preventive services can be provided without referrals when performed by network providers, except for active duty service members (ADSMs). ADSMs generally receive most of their health care at a military treatment facility (MTF) and any care received outside the MTF needs authorization.

TRICARE-eligible dependents who are at least 5 years old and less than 12 years old may get physical exams that are required by a school in connection with the enrollment of the dependent as a student in that school. This benefit does not include physical exams that may be required by the school solely to participate in school sports.

Routine physical examinations are not a TRICARE covered benefit. However, when required by the uniformed services, claims may be covered for physical examinations provided for family members traveling outside of the United States as a result of their sponsoring ADSM's assignment. Such claims must be accompanied by documentation indicating the ADSM's overseas assignment.

When billing for preventive services, remember that TRICARE coverage is based on medical necessity, and diagnoses should reflect that. Be careful to follow CPT and ICD-9 regulations when billing and choose a specific diagnosis. Avoid using V codes whose designations start with "unspecified." Choose a more specific diagnosis code to establish medical necessity or family history of a condition to avoid having your claim inappropriately denied.

For more information about preventive services, refer to the newly updated Provider Handbook.