# Medicare G code



## mlbaker1974

I have a denial from medicare, stating that I need a G code, services provided were general physical examination with breast and rectal exam, no pap or GU exam was performed....Would G0101 be appropriate even if the GU exam was not performed? And would I still use the V70.0 Dx? Any assistance would be greatly appreciated.


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## heatherwinters

*Denial*

What CPT and ICD-9 code did you bill?


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## mlbaker1974

99397 with dx V70.0, V76.19,v10.3,V76.41


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## heatherwinters

*Medicare Preventive Services*

Medicare does not normally pay for preventive services 99397.  Digital Rectal Examinations are covered for male patients for prostate screening, however, they are not covered for female patients.  If an occult stool test was done, you can bill that with a G code and the V76.41.  You can check on preventive services coverage at the following link.

http://www.cms.hhs.gov/MLNProducts/35_PreventiveServices.asp#TopOfPage


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## mlbaker1974

Thank you


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## ckkohler

*G0101 plus 99397*

Is it appropriate to bill G0101 WITH 99397?  I'm thinking it is - but, my mom is questioning a bill from her physician.  To my knowledge, there is nothing illegal or fraudulent with un-bundling services is there?

Thanks!


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## apeck

also there is a GY that goes in front of the level of servie for medicare only...keep in mind if its a pap a 25 modifer applies to the level of service. This is only for medicare patients.


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## Lisa Bledsoe

ckkohler said:


> Is it appropriate to bill G0101 WITH 99397?  I'm thinking it is - but, my mom is questioning a bill from her physician.  To my knowledge, there is nothing illegal or fraudulent with un-bundling services is there?
> 
> Thanks!



If the doctor did a pelvic and breast exam s/he can bill G0101 with 99397.  The fee for G0101 must be deducted from the fee for 99397, so your mom's bill for 99397 should be a little less than her doctor's normal fee.  If they did not reduce 99397 by the amount billed for G0101 she needs to call the billing dept and get that worked out.


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## Betsy Nicoletti

*G0101*

Medicare clarified recently that in order to bill the G0101 you must do the breast exam (which it sounds like was done) and a total of 7 of the 11 exam elements defined by G0101.  So, it doesn't sound like you can bill that code.

It is appropriate to bill a 99397 and a G0101 to a Medicare patient, and the Q0091 (obtaining the pap smear) when all were performed.  Of course, Medicare will pay on the G and Q codes, but the patient pays the difference between the fee for the 99397 and the fee for the covered Medicare services.

If your provider also addressed medical problems, and these are clearly documented, you can bill Medicare for an office visit, as well, and subtract the fee for that from the 99397.


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## RebeccaWoodward*

Betsy,

Your name rings a bell with me.  Have you conducted an E/M Seminar on Physician Pearls?


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