Internal Medicine Coding Alert

Question: After our internist performed a Pap smear and pelvic exam on a Medicare patient, he sent the collected specimen to a lab for testing. What codes should I report for these services? Do I need a modifier?

Georgia Subscriber

Answer: When the internist performs a complete well-woman exam on a Medicare patient that includes breast and pelvic exams, you should report G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination). If the physician provides only a pelvic exam, you can assign the appropriate E/M code (99201-99205, 99211-99215).
 
For the Pap smear, use Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory), because this code represents the collection and preparation of the Pap sample. Code Q0091 does not include the physician interpretation. The lab will bill for the interpretation services.