Ob-Gyn Coding Alert

Warning: Be wary of Q0091, G0101 - they generally won't apply.

A patient who underwent a hysterectomy may present a coding challenge when it comes to coding a Pap smear, but don't worry. Your solution relies on one key question: was this diagnostic or screening?

Beware: The rules for coding standard Paps aren't the same for Medicare patients who underwent a hysterectomy due to malignancy.

Pinpoint the Post-Hysterectomy Pap Claim Problem

When a Medicare patient returns after a hysterectomy (for a malignant condition) for follow-up vaginal Pap smears in your office, should you report 99212 or 99213, or should you just report Q0091?

Watch out: First of all, you should not report Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory), because this code refers to collection of a screening Pap smear.

After a hysterectomy that the ob-gyn performed to treat cancer, all of the Paps will be diagnostic, not screening. 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 Medicare includes the collection in the E/M service.

Confront the Years-Afterward-Pap-Smear Question

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

Reality: The Pap code (Q0091) remains the same. If the purpose of the E/M visit is to follow up for the patient's cancer, then the Pap smear is diagnostic, not screening, 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 unless the woman has a history of cancer within the past 3 years and is still of childbearing age (for example, Z85.42 (Personal history of malignant neoplasm of 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.

G Code Refers Only to Screening

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.

Keep in mind: For Medicare patients, you have to have examined 7 of the 11 exam elements for a pelvic exam (G0101). If your ob-gyn is dealing with a post-hysterectomy patient, then he can state, "the uterus, cervix and ovaries are surgically absent," and that may count, but be aware that some coders are finding this is not the case during an audit. Medicare has never created a guideline to address this issue.

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 that capture this fact. The only correct codes to report in this situation would be Z08 (Encounter for follow-up examination after completed treatment for malignant neoplasm), Z90.710 (Acquired absence of both cervix and uterus), and Z85.40-Z85.42 (Personal history of malignant neoplasm of female genitourinary organ). But Medicare does not recognize these codes for purposes of billing the G and Q codes. Medicare will accept Z12.72 (Encounter for screening for malignant neoplasm of vagina) for a screening vaginal Pap smear, but this code can only be reported when the patient's uterus was removed for non-malignant reasons.

Keep in mind: Because Medicare does not accept Z08 when you bill either the G or Q code, you have two options:

1) bill G0101 and Q0091 with Z08 and receive a denial, or
2) bill a diagnostic Pap and exam annually with the correct codes.

Some coders have had luck persuading their Medicare carriers to put into writing that they can use one of the approved codes (such as Z12.4 [Encounter for screening for malignant neoplasm of cervix] if she has a cervix, or Z12.72 [Encounter for screening for malignant neoplasm of vagina] 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.