EM Coding Alert

Medicare says yes; CPT^® not so much.

When your female patients report for their yearly physicals, are getting your full reimbursement? If you don’t know the difference between Medicare and private payer guidelines, chances are you’re not.

So, here’s a quick rundown of the rules to help you boost your bottom line easily and ethically.

Understand the Visit Codes

You’ll typically report an annual physical with a preventive E/M service such as 99396 (Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years) or 99397 (…65 years and older). The correct code will depend on the patient’s age and whether the patient is new (99381-99387) or established (99391-99397) with your practice.

Inclusions: Notice that these codes include the physical exam as well as the ordering of laboratory/diagnostic procedures, such as a Pap smear. Also note that, from a CPT^® perspective, the services to obtain the Pap smear are inherent in the service being performed and are not reported separately.

You can report code 99000 (Handling and/or conveyance of specimen for transfer from the office to a laboratory) for the handling and conveyance of the specimen to an outside laboratory if you incur costs over and above normal practice expenses. Be aware, however, that many payers, including Medicare, consider this a bundled service and will not pay separately for it.

“Remember that 99000 is not a stand-alone code,” notes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians in Leawood, Ks. “You should always report it in addition to the basic services rendered. In this case, that would be a preventive medicine visit.”

Watch for Medicare Differences

Medicare benefits include a screening Pap smear and cervical or vaginal cancer screening, including pelvic and clinical breast examination. Because these are Medicare benefits and because Medicare does not otherwise cover the preventive medicine service codes (described above) that would normally include the services, Medicare created separate codes for both benefits. You should report Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) and G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) when your physician provides these services to a Medicare beneficiary in the covered year.

Commercial pay: Because CPT^® considers Pap smear collection to be part of the visit being performed and because a breast and pelvic exam may be considered part of “an age and gender appropriate . . . examination,” most private payers do not pay separately for Q0091 and G0101 when done in conjunction with a preventive medicine visit. Some private payers might not reimburse for either code under any circumstances, even if the Pap collection and preventive visit take place on separate dates. Your best bet is not to submit these codes to a private payer with a preventive service code unless you know that the payer recognizes and pays for them like Medicare does.

Choose the Diagnosis Carefully

The diagnosis for a routine gynecological examination, such as an annual well-woman visit, is Z01.411 (Encounter for gynecological examination [general] [routine] with abnormal findings) and Z01.419 (... without abnormal findings). Per ICD-10, this diagnosis includes a general gynecological examination with or without a cervical Pap smear, as well as an annual or periodic pelvic examination.

If your physician completes a routine vaginal Pap smear in conjunction with the visit, ICD-10 directs you to also report Z12.72 (Encounter for screening for malignant neoplasm of vagina). If, for whatever reason, your physician does not consider the yearly physical a routine gynecological examination, the alternative is to report a diagnosis of either Z00.00 (Encounter for general adult medical examination without abnormal findings) or Z00.01 (Encounter for general adult medical examination with abnormal findings).