Ob-Gyn Coding Alert

To estimate what your practice should charge a Medicare patient when your ob-gyn performs a preventive service as well as an E/M service at the same visit means applying the "carve out" rule. Depending on whether the patient's annual exam is covered, your outcome will be very different.

Our experts break this sometimes puzzling rule into terms you can understand.

For Medicare beneficiaries, you should take your normal charge amount of the preventive service minus the charge amount for the sick visit. This will give you the total amount you can bill the patient for the preventive part of the visit.

Example: A 66-year-old established patient comes in for her yearly exam. Last year when she presented for her annual exam, you billed Medicare for the breast, pelvic, and Pap, and it was reimbursed. Remember: "Medicare will pay for these services once every two years," says Arlene J. Smith, CPC, insurance specialist at Tacoma Women's Specialists in Wash.

When the ob-gyn enters the examination room, the patient complains of pain in her left-lower quadrant and blood in her stool. The physician documents an expanded problem-focused history regarding the problem, then completes the annual exam and collects a Pap smear specimen. He orders an abdominal ultrasound and performs an immunoassay test for fecal blood.

First, you would report a well-woman exam (99397, Periodic comprehensive preventive medicine re-evaluation and management of an individual including an age- and gender- appropriate history... established patient; 65 years and older) with modifier GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefit) appended. Modifier GY tells Medicare you know this is not covered, but you need a denial so the patient's secondary insurance will pay the non-covered portion, Smith says. Link this code to V72.31 (Routine gynecological examination).

Secondly, according to your ob-gyn's documentation, you might add 99213 (Office or other outpatient visit for the evaluation and management of an established patient -) with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Link that with 789.04 (Abdominal pain; left lower quadrant) and 578.1 (Blood in stool).

No double dipping: You must be vigilant about checking your documentation, as "you cannot use any part of the documentation for the preventive exam to determine the level of service for the E/M code," Smith says.

Tip: Ask yourself, "can I find enough carved-out history, exam and medical decision-making to support an E/M service that is not part of the preventive care?" says Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.

Bottom line: In the above example, the patient's additional problems and the physician's additional work present sufficient reason to report the problem-oriented portion of the visit separately.

Suppose the office fee for 99397 is $150.

Your office also normally charges $75 for 99213 (Office or other outpatient visit for the evaluation and management of an established patient -).

If you-re billing both a preventive visit and the office visit to Medicare, then you should subtract these amounts. In other words, the amount you can charge the patient for the non-covered portion is $150 - $75 = $75.

Translation: The $75 is what the patient owes for the non-covered service (or the amount you will be submitting to her secondary insurance). Don't forget: The patient will also be responsible for paying her share of the Medicare allowable and any applied deductible for the problem service.

Watch out: You should not charge $150 for the preventive visit and then also collect reimbursement for the office visit (99213).

A year in which you can report the Medicare Pap, pelvic, and breast exam requires different calculations.

Example: An established 68-year old Medicare patient comes in for her annual exam including her Medicare covered Pap, pelvic, and breast exam. Then the ob-gyn managed the patient for urinary stress incontinence at this same visit.

You would bill the patient for the non-covered portion of the exam (99397-GY) and maybe 99213-25 for the office exam, but you will also be billing Medicare for the covered part of the screening exam.

Bill Medicare using G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) and Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory), Smith says. Don't forget "modifier GA (Waiver of liability statement on file) when the patient signs an advance beneficiary notice (ABN)," Smith adds.
Altogether, your claim would look like this:

- 99397-GY (billed to Medicare to get a denial)

- 99213-25

- G0101-GA (ABN signed in case Medicare does not cover this at the time of service)

- Q0091-GA (ABN signed)

Estimate the patient's payment: First of all, take these assumptions into account:

- 99397=$150 (This is the practice's established fee for the preventive service)

- 99213=$75 (The Medicare allowable is $64, but this practice has a fee of $75 on 99213 and this is what they bill to all carriers including Medicare)

- G0101=$37 (Medicare allowable should be billed by the practice rather than setting a practice fee that is higher than the allowable since this is only ever covered by Medicare)

- Q0091=$42 (Medicare allowable)

First, subtract the office visit from the preventive service ($150-75=$75), then subtract G0101 (75-37=38), then subtract Q0091 (38-42= negative value).

Result: Because you reach a negative value, the patient owes nothing for the non-covered service. The total services you-re billing to Medicare are greater in value than the fee for the preventive service from which all other services are a component.

Heads up: The patient will still be liable for the co-pay that applies to 99213 (and any deductible she still owes) and the co-pay on the G and Q codes (but a deductible does not apply).