Currentmoda_health_plan_incPolicy RPM037
Preventive Services versus Diagnostic and/or Medical Laboratory Services
Customize your policy alerts
Sign up for moda_health_plan_inc Policy RPM037 alerts
Get alerted when Policy RPM037 changes without checking for updates manually.
Monitor payer policy activity
Receive email alerts as soon as relevant payer policies are published or updated.
Defines how Moda Health classifies and processes laboratory tests and related services as preventive (screening/routine) versus medical/diagnostic, including billing, member/provider financial responsibility, and coding guidance for commercial lines of business and all provider contract statuses.
Policy Summary
Payermoda_health_plan_inc
PolicyPreventive Services versus Diagnostic and/or Medical Laboratory Services
Policy CodePolicy RPM037
Change TypeAdministrative review — no material changes
Effective DateJul 8, 2026
Last ReviewJul 8, 2026
Next Review DateJul 8, 2026
Key ActionSubmit the correct diagnosis code to classify a lab test as preventive or medical to ensure proper coverage and member/provider cost assignment.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
100%PPACA-mandated preventive services covered with no member cost-share when in-network
~30 codesAdditional lab CPT codes eligible for preventive/screening billing (limited list)
02/01/2015Waiver/member liability rules effective date for non-covered screening tests
06/01/2024Effective date for Medical Necessity Criteria change for Vitamin D testing
Coverage criteria and classification
Coverage criteria for preventive vs medical lab services
Coverage depends on whether the service is mandated under PPACA, included on Moda's limited preventive list, or billed with a medical diagnosis.
Services are processed according to the diagnosis code submitted; proper payment of preventive services requires claim submission using diagnosis and procedure codes that identify the service as preventive.
PPACA-mandated preventive services are covered at 100% with no member cost-share when performed by an in-network provider.
children":[]}
All other laboratory procedure codes and diagnostic services are covered only when billed with a medical diagnosis indicating symptoms or problems; they are considered non-covered and will be denied if billed with a routine/preventive diagnosis.
Tests ordered because of problems existing prior to a preventive visit, abnormalities found during the visit, or new problems encountered during a preventive visit must be billed with the medical diagnosis describing the problem (not the preventive visit code); such tests are considered Medical, not Preventive.
Financial responsibility for non-covered screening lab tests is generally assigned to the provider unless a valid member waiver of liability is on file and the correct waiver modifiers are billed; when GA or GX (or GA/GX) are appended and a valid waiver exists, denial may be processed to member responsibility per waiver rules.
Coverage classification guidance
Coverage classification guidance based on presence of symptoms, known conditions, or risk factors; modifier use for preventive services.
Diagnostic classification: If the member has symptoms or health problems (a problem already exists), tests and procedures ordered to determine the cause are Diagnostic and are considered Medical; they are never Preventive.
Preventive classification: If the member has no signs, symptoms, abnormal findings, or history of the disease, tests/services performed to detect undiagnosed disease are screening/routine/ preventive.
Routine monitoring: Testing to monitor an existing known condition (routine monitoring) is not preventive; the code and benefit must reflect the known condition and is processed as Medical.
Surveillance testing is Medical when monitoring a known symptom/problem (diagnosis code must indicate the problem); surveillance is considered Preventive when performed because of risk factors or family history.
Modifier 33 use: Apply modifier 33 when the primary purpose is delivery of an evidence-based USPSTF A or B service or other mandated preventive services; do not use modifier 33 for services already separately identified as preventive.
Colorectal screening conversion: Use modifier PT for colorectal cancer screening tests converted to a diagnostic test or other procedure.
Diagnosis code categories: 'Personal history of…' codes are considered Medical; 'Family history of…', 'Screening', 'Routine', and 'Prophylactic' diagnosis codes are considered Preventive. Z-codes are evaluated by description and are not automatically Preventive.
Code lists, modifiers, and billing rules
Lab CPT codes eligible for preventive/screening diagnosis processingCPTCovered
| 80048 | Basic metabolic panel |
| 80050 | General health panel |
| 80051 | Electrolyte panel |
| 80053 | Comprehensive metabolic panel |
| 80061 | Lipid panel |
| 80076 | Hepatic function panel |
| 81001 | Urinalysis, by dip stick or tablet reagent; automated, with microscopy |
| 82248 | Bilirubin; direct |
| 82270 | Fecal occult blood, guaiac |
| 82274 | Fecal immunoassay for hemoglobin, qualitative |
1–10 of 34
1/4
ModifiersModifier
| Modifier 33 | Preventive Services modifier for evidence-based USPSTF A/B and other mandated preventive services |
| Modifier PT | Colorectal cancer screening test converted to diagnostic test or other procedure |
| Modifier GA | Waiver of liability statement issued as required by payer policy |
| Modifier GX | Notice of liability issued, voluntary under payer policy |
Waiver validity window
Waiver signature timingMember must sign and date a waiver of liability on or prior to the date of service.
Service window after waiverServices must be performed or initiated within 30 days of the waiver signature for the waiver to apply.
Ongoing treatment validityFor an ongoing course of treatment and/or rental, the waiver is valid for no more than one year from the member signature; a new waiver is required before billing additional services beyond one year.
Provider billing and documentation actions
Documentation Required
Diagnosis coding determines benefit category
Submit accurate diagnosis codes that clearly identify whether a test is preventive or medical; codes indicating 'family history', 'screening', 'routine', or 'prophylactic' are treated as preventive, while 'personal history of…' codes are considered medical. Z-codes are evaluated by their description and are not automatically preventive.
- Use screening/routine/prophylactic or family-history diagnosis codes to establish preventive benefit processing (e.g., Z00.121, Z00.129, Z00.00, Z00.01).
- Do not rely on chapter placement alone for Z-codes — the code description determines preventive vs medical classification.
- If the member has signs, symptoms, or a personal history relevant to the test, bill with a medical diagnosis so the service is processed under the Medical benefit.
Billing Rule
Waiver and modifier requirements for member liability
When a non-covered screening test is to be billed to the member, obtain a signed waiver of liability on or before the date of service and bill with modifier GA or GX; the waiver must be available on request and accompany any corrected claim submitted without the modifier.
- Waiver must be signed and dated by the member on or prior to the date of service.
- Services must be performed within 30 days of the waiver signature (or waiver valid up to one year for an ongoing course of treatment, after which a new waiver is required).
- Procedure codes must be billed with modifier GA or GX appended.
- Be prepared to submit the waiver form upon request (and include it with a corrected claim if GA/GX was not on the original claim).
- Absent a valid waiver and correct modifier, non-covered screening procedure denials will be assigned to provider responsibility.
Billing Rule
Modifier guidance (33, PT, GA, GX)
Apply modifier 33 when the primary purpose is delivery of an evidence‑based USPSTF A/B or other mandated preventive service; do not use modifier 33 for services that are separately reported and already specifically identified as preventive. Use PT for colorectal screening conversions and GA/GX for liability notices per policy.
- Modifier 33: identify services delivered in accordance with USPSTF A/B recommendations or other mandated preventive services; omit when a service is separately identified as preventive.
- Modifier PT: use when a colorectal cancer screening test is converted to a diagnostic test or other procedure.
- Modifiers GA and GX: used for waiver/notice of liability handling when member agrees to accept financial responsibility.
Definitions and terminology
Preventive / Routine / Screening / Prophylactic
DefinitionServices performed when the member has no signs, symptoms, abnormal findings, or history of the disease; provided to help the member avoid becoming sick; synonymous in insurance terms with routine, screening, or prophylactic.
Typical coding indicatorsDiagnosis codes described as 'screening', 'routine', 'family history of…', or 'prophylactic' are considered preventive (check benefits for family history codes).
Benefit implicationPreventive services may be PPACA-mandated (100% in-network no cost-share) or included on Moda's limited preventive lab list; non-mandated preventive items may be subject to cost-sharing.
Medical / Diagnostic
DefinitionServices and tests ordered to diagnose, treat, or monitor a known medical condition, symptom, or health problem; considered Medical benefit and never Preventive.
Coding indicators'Personal history of…' diagnosis codes and diagnosis descriptions indicating an existing problem are treated as medical/diagnostic.
PurposePerformed to obtain information to aid assessment, identify disease, determine nature/severity of an ailment, or guide treatment and monitoring.
Acronyms
PPACAPatient Protection and Affordable Care Act.
RPMReimbursement Policy Manual.
TACTexas Administrative Code.
Diagnostic Services
DefinitionDiagnostic services/tests are ordered to determine the cause of symptoms or health problems and to obtain information to assess or identify disease; they are categorized as Medical and never Preventive.
PurposeAid assessment of a medical condition, determine nature and severity of an ailment or injury, and guide diagnosis/treatment.
Coding implicationWhen symptoms or problems exist, code and bill as medical/diagnostic—not preventive.
Preventive Services
DefinitionPreventive services are provided to help a member avoid becoming sick; performed when the member has no signs or symptoms and are synonymous with routine, screening, or prophylactic in insurance terms.
ExamplesEducation, immunization programs, routine screening tests and services performed on asymptomatic individuals.
Coverage noteSome preventive services are PPACA-mandated and covered at 100% in-network; other preventive lab tests may be covered per Moda's limited list and subject to cost-sharing.
Routine
DefinitionRoutine services (insurance term) are synonymous with screening or preventive and are recommended for seemingly healthy individuals with no known problems, symptoms, chronic conditions, or injuries.
Context'Routine' may also refer to routine monitoring of a known condition in clinical language, but that usage does not imply preventive benefit in insurance terms.
Coding guidanceUse routine/screening diagnosis codes only when no signs, symptoms, or history of disease exist; otherwise bill as medical.
Routine Monitoring
DefinitionRoutine monitoring is testing or care to monitor an existing health condition (e.g., diabetes, high cholesterol) and is not considered a preventive service for benefit classification.
Benefit implicationTesting for known conditions is covered under the relevant medical benefit category, not as preventive care.
Coding requirementCode and bill to reflect the known condition to ensure processing under the appropriate medical benefit.
Screening Services
DefinitionScreening services are tests performed on seemingly well individuals without symptoms, abnormal findings, or past history of the disease to detect undiagnosed disease or disease precursors for early detection and treatment.
Use casePerformed to identify disease in asymptomatic patients so treatment can begin if positive.
Coding guidanceUse screening/routine preventive diagnosis codes when the member is asymptomatic and no history of the disease exists.
Surveillance
DefinitionSurveillance is close and continuous observation or testing; classification depends on purpose and diagnosis coding.
Medical classificationSurveillance testing is considered Medical when performed to observe or monitor a known symptom or problem; the diagnosis code must indicate the problem being monitored.
Preventive classificationSurveillance testing is considered Preventive when conducted because of risk factors (e.g., work environment) or family history rather than an existing problem.
Policy Summary
Payermoda_health_plan_inc
PolicyPreventive Services versus Diagnostic and/or Medical Laboratory Services
Policy CodePolicy RPM037
Change TypeAdministrative review — no material changes
Effective DateJul 8, 2026
Last ReviewJul 8, 2026
Next Review DateJul 8, 2026
Key ActionSubmit the correct diagnosis code to classify a lab test as preventive or medical to ensure proper coverage and member/provider cost assignment.
SourceLink
On This Page
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.