Ob-Gyn Coding Alert

Don't be tempted by Q0091 and G0101 -- they generally won't apply

If you code a Pap smear for a Medicare patient who underwent a hysterectomy due to malignancy, you won't want to follow the same rules as you would when you code standard Paps. Follow our experts'coding advice to determine how you should bill these procedures.

"When a Medicare patient returns after a hysterectomy (for a malignant condition) for follow-up Pap smears in our office, we report 99212 or 99213. Can I charge for this visit, or should I just report Q0091?" a subscriber to Ob-Gyn Coding Alert recently asked.

You should not report Q0091 (Screening Papani-colaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory), because it refers to collection of a screening Pap smear.

Remember: After a hysterectomy that the ob-gyn performed to treat cancer, all of the Paps will be diagnostic, not screening. According to Section 50-20 of the Medicare Coverage Issues Manual (CIM), "a case-by-case evaluation to determine if a malignancy of another site constitutes a reasonable uterine threat" qualifies as a "diagnostic Pap as opposed to a screening Pap smear (covered under CIM 50-20.1)." Therefore, you should report the Paps with an E/M code (for example, 99213, Office or outpatient visit for the evaluation and management of an established patient ...), but payers now include the collection in the E/M service.

But what if the ob-gyn conducts the Pap smear six years after the hysterectomy? Could you submit Q0091?

"The Pap code (Q0091) remains the same," says Cheryl A. Lewis, CPC, billing manager for ZIA Ob-Gyn Ltd. in Yuma, Ariz. If the purpose of the E/M visit is to follow up for the patient's cancer, then the Pap smear is diagnostic, coding experts say. If the ob-gyn wishes to put the patient back into the screening group, then she reverts to one Pap smear every two years instead of one each year, under Medicare rules, because the Medicare criteria list for screening each year does not include a history of cancer (for example, V10.42, Personal history of malignant neoplasm; other parts of uterus). If your physician thinks the patient requires a yearly Pap smear, considering her history, it will have to be a diagnostic service with the collection of the specimen included in the E/M code.

Similarly, G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) involves a screening exam, not a diagnostic exam. Therefore, as long as the ob-gyn doesn't use the cervical or vaginal exam to check for cancer for the post-hysterectomy Medicare patient, you can report G0101. On the other hand, if he does perform a cancer check, insurers will include the pelvic exam in the E/M service.

No diagnosis: Keep in mind, however, that if your physician does place a patient back into the screening pool after she had a hysterectomy because of malignancy, there are no diagnosis codes that Medicare will accept with G0101 and Q0091, says Lana Flatt, a veteran coder for Ob Gyn Associates in Cookeville, Tenn. The only correct code to report in this situation would be V45.77 (Other postprocedural states; acquired absence of genital organs). This is correct coding, but will not help you collect reimbursement with the G and Q codes.

Keep in mind: Because Medicare does not accept V45.77 when you bill either the G or Q code, you have two options: 1) bill G0101 and Q0091 with V45.77 and receive a denial, or 2) bill a diagnostic Pap and exam annually with the correct code.

Some coders have had luck persuading their Medicare carriers to put into writing that they can use one of the approved codes (such as V76.2 if she has a cervix, or V76.47 if she does not), even though the patient had cancer. If your carrier agrees, you can bill the G and Q codes every two years.

Remember: You should use the code that is correct, not the code that gets the service paid.