Preventive care vs. office visit

What’s the difference?

Note: The information below is for general reference only. Check your specific insurance plan for coverage related to preventive care services and office visits.

If your goal is to stay healthy, an annual checkup is a good practice to start.

Many insurance plans cover an annual visit as a preventive care service at no out-of-pocket expense to the patient. But what happens when the visit involves unexpected treatment for a health issue, similar to a sick visit? Is there a charge?

According to the American Medical Association (AMA), physicians are NOT prohibited from coding and billing for both preventive and problem-focused services when they are performed during the same appointment. That is because better patient care is achieved when health issues are addressed promptly. The AMA further states that “the significance of the problem addressed, and the amount of time and medical decision-making required, help determine how the services are most appropriately billed” to ensure accurate record keeping.

Understanding the difference between a preventative visit and an office visit can be helpful.

Preventive Visit

A preventive visit is a yearly appointment intended to prevent illnesses and detect health concerns early, before symptoms are noticeable or a condition diagnosed. Depending on the insurance plan, this type of visit may be called an annual physical or wellness exam.

The purpose of a preventive visit is to review overall health and wellbeing. This visit often includes the following and varies by age and gender:

• Complete physical exam
• Blood pressure, blood glucose & cholesterol screening tests
• Pelvic exams, pap smear
• Prostate & colorectal cancer screenings
• Sexually transmitted disease testing
• Immunization review & update
• Developmental screenings

Office Visits

A scheduled office visit focuses on medical treatment for an acute or chronic condition. It usually involves an insurance copay and can include other costs. A typical office visit may include the following:

• Discussions about new or existing health problems, such as diabetes, pain, medication adjustment and refills, and chronic conditions (high blood pressure, high cholesterol, etc.).
• Prescription medications, lab work, or other testing ordered by the provider. The discussion may include treatment options and a referral to a specialist.