Ob-Gyn Coding Alert

Because Medicare's policy is not to pay for "preventive" care, these are considered "screening" services, or "those services rendered in the absence of an illness, disease, or symptom." "The frequency with which Medicare will pay for these services is determined by the patient's risk category," Witt explains.

Used to check for osteoporosis, bone density studies are payable by Medicare for a number of reasons, but the one closest to a true "screening" exam is when the patient is documented as estrogen-deficient. The study will be reimbursed every two years if the documentation clearly shows that the patient is estrogen-deficient by medical history or other findings. Medicare carriers have identified the following diagnoses as showing estrogen deficiency:

Depending on local Part B carrier rules, submit one of the following codes for the bone scan:

You should note that although G0131 and G0132 are similar to 76070 (Computerized axial tomography bone density study, one or more sites), the CPT code will be denied if billed to Medicare.

For Medicare-eligible women between the ages of 35 and 39, Medicare will reimburse for one baseline mammogram. At 40 years of age and older, Medicare will pay for one mammogram every year. For patients who are considered low-risk, meaning there is no personal or family history of breast cancer, use diagnosis code V76.12 (Other screening mammogram). Women with the following conditions/complications are deemed at high risk for developing breast cancer:

For these high-risk patients, submit V76.11 (Screening mammogram for high-risk patient) in addition to the V code that describes the patient's risk category. But you should note that being in a high-risk category does not necessarily mean that the mammography will be paid more than once a year.

Medicare-approved procedural codes for screening mammograms are:

tation, screening mammography (list separately in addition to code for primary procedure) for conversion to digital mammography

When a screening mammogram indicates a problem, the physician may order a diagnostic mammogram immediately following the screening mammogram to further identify the problem. The screening and diagnostic mammogram can be billed together by adding modifier -GG (Performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day) to one of the following diagnostic codes:

Physicians order screening sigmoidoscopies to check for the presence of colorectal cancer. The procedure involves a small scope that examines the lower tract of the large intestine. Usually the patient does not have to be anesthetized, and there is little preparation for the test. In patients more than 50 years of age, Medicare will pay for the procedure every two years. If a screening colonoscopy has been performed on the patients within the preceding 10 years, however, Medicare will only cover the sigmoidoscopy 119 months after the colonoscopy. The procedure is not normally performed by an ob/gyn, but may be recommended to the patient during her annual exam. When ordering the test, the physician should specify a diagnosis so that the performing physician can be reimbursed for it. The sigmoidoscopy is coded G0104 (Colorectal cancer screening; flexible sigmoidoscopy) and is paired with one of the following diagnostic codes:

Witt explains that a colonoscopy differs from a sigmoidoscopy in that it examines the entire colon and is a much more "invasive" procedure. Again, this normally would not be performed by an ob/gyn, but may be ordered by one, so understanding the Medicare requirements will be important. For patients deemed at low risk for colorectal cancer, regardless of age, Medicare will pay for a colonoscopy every 10 years. For these patients, the procedural code is G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk), paired with one of the following diagnostic codes:

In a high-risk patient (one with a personal or family history of colorectal cancer or colitis), the correct screening code is G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) and is payable every two years. G0105 is paired with one or more of the following diagnostic codes:

Both colonoscopy and sigmoidoscopy are screening tests. Harry Stuber, MD, a gynecologist based in Cookeville, Tenn., explains that colonoscopy is the more accurate of the two procedures because a sigmoidoscopy can miss 50 percent of lesions. "Sigmoidoscopy is pretty much risk-free," Stuber says, "while colonoscopy is more accurate but involves IV medications and carries a 1/5,000 risk of perforation." Physicians often present both options to the patient and let her choose which test to undergo. "However," Stuber adds, "if in the interim period between the tests, the patient shows symptoms such as rectal bleeding, a diagnostic procedure can be ordered as needed."

Used to detect colorectal cancer early, a fecal occult blood test involves the patient taking samples from two different stool sites of three consecutive stools, placing these samples on a test card, and returning the card to the physician's office for analysis of peroxidase activity. In women older than 50 years of age, Medicare will pay for the procedure once a year. The code for the occult test is G0107 (Colorectal cancer screening; fecal-occult blood test, 1-3 simultaneous determinations), paired with V76.41 (Special screening for malignant neoplasms; rectum) or V76.49 ( other sites). "Some practices have been incorrectly billing this code when the physician collects the sample and runs the test at the time of the exam. It is important for ob/gyn practices to understand that the benefit is only paid when the patient takes the sample otherwise it is a free service," Witt says.

Further information about Medicare screening services for women can be found at:

Note: Practices should remember that a cholesterol screening test is not classified as a "screening" benefit under the Medicare rules.