# Medicare Pap Smear and office visit



## jhendrix08 (Mar 6, 2018)

We have a patient that does not want to have a full physical exam since Medicare doesn't cover it and she is unable to pay out of pocket for the uncovered portion. Can we see the patient and bill an E/M code for the office visit portion to discuss lab results and then bill CPT Q0091 and G0101 for the pap, pelvic and breast exam? Will Medicare still pay for E/M? If so, do I use modifier 25 on the office visit?  (we are her PCP)

Thanks!!


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## Pam Brooks (Mar 7, 2018)

*Q*

Medicare does cover certain preventive visits;  the IPPE (i.e. the 'Welcome to Medicare Visit) and the AWV (Annual Wellness Visit). There are certain guidelines from a documentation perspective that you would need to meet, so I wouldn't recommended billing these with the same documentation acquired for a well-woman visit. I did want to point that out.  

Your question is a good one, but one that does border on whether you think it's ok to potentially submit a false claim.  I get what you're trying to do....provide a service to a patient, and get paid at the same time.  Hear me out, please.  

In general,  you can bill an E&M visit with a Pap/Pelvic, as long as you can report significant and separately identifiable documentation for the key components to meet the E&M visit. And there must be a problem/complaint; this cannot be used to report screening visits. Discussion of lab work would be appropriate only if there is a confirmed diagnosis, or if the discussion had to do with a treatment plan that would be put in place based on the reason and results of the lab work.  I am not sure if that alone would be considered significant.  The Key components must address and be related to the reason/results of the lab work, and or any other complaint ONLY. It may not be appropriate to perform a comprehensive history, and a comprehensive exam in order to discuss lab work.  "Fluffing up" documentation just to bill a preventive physical as an E&M (so that you get paid) when your complaint is of low complexity, is considered fraud.

Yes, you would use -25 on the E&M.  Be careful to not count the pap/pelvic exam components as part of your E&M; that would be unbundling.  

It also  wouldn't be appropriate to discuss preventive counseling and bill out a 9921x.  In that case, you'd bill a preventive counseling code (which Medicare also doesn't cover).  

Depending on the volume of additional work being done by the physician for the lab work discussion, it may be appropriate to only bill the Q0091 and G0101.


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## jhendrix08 (Mar 7, 2018)

I appreciate you taking the time to give such a detailed explanation....this makes a lot of sense. I'm printing this for my future reference.  Thanks so much!


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