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Internal Medicine Coding Alert

Reader Question:

Pelvic/Breast Exam Fees

Published on Sun Jul 01, 2001

Question: The current Medicare fee schedule for Vermont allows only $28 for a gynecological checkup  less than what we receive for a focused 99212 visit. The allowed fee for a Pap smear is $27. What is Medicare paying for this exam (which usually takes about 30 minutes) in other states?

Vermont Subscriber 
 
Answer: The correct codes for a screening gynecological exam are G0101 for the pelvic/breast exam and Q0091 for obtaining and preparing the specimen. According to information in the Federal Register, when these codes were established, payment was to be consistent with a 99212. In 1998, when these codes went into effect, the Florida Medicare carrier was reimbursing about $27 for each code.

However, based on the 2001 fee schedule, Florida is now reimbursing an average of $40 for each of these codes. It appears as though Vermont has not updated its fee schedule. In addition, according to the Federal Register, effective 1999, modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) should be appended to the E/M code when both the pelvic/breast exam (G0101) and office visit occur at the same encounter for distinct reasons. The same rule applies when an E/M service is billed with a Pap smear screening (Q0091).
 
-- This month's "You Be the Coder" and "Reader Questions" were answered by Kathy Pride, CPC, coding supervisor for the Martin Memorial Group, a 57-physician group practice in Stuart, Fla.

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