Ob-Gyn Coding Alert

Traditionally, Medicare has not covered preventive medicine services. But because of a new provision in the Balanced Budget Act of 1997, Medicare will now reimburse for certain such services for women it covers. The new policy became effective January 1, 1998 and provides coverage for pelvic and breast examinations, in addition to screening Pap smears (which Medicare has covered for several years). This new coverage allows for these examinations every three years for women not at risk, and annually for women who are considered to be at high risk or with specific histories.

Also, annual preventive coverage is for women who are of childbearing age and have a personal history of cervical or vaginal cancer or, in the preceding three years, have had a Pap smear indicating the presence of cancer or other abnormalities.

Annual coverage is also provided for women considered high risk for cervical or vaginal cancer, based on whether they have any of the following criteria:

1) For cervical cancer:

- sexual intercourse prior to age 16

- five or more sexual partners in lifetime

- a personal history of sexually transmitted disease

- the absence of any Pap test in the last 7 years

- the absence of three negative Pap smears

2) For vaginal cancer:

- prenatal exposure to diethylstilbestrol (an estrogen-like preparation often known as DES)

The screening exams must be performed by an MD/DO, PA, NP or CNM and must always include documentation of seven of the following 11 elements:

1) Inspection of breasts (symmetry and nipple discharge) and palpation of breasts & axilla for masses lumps or tenderness.

Tip: The inspection of breasts must always be included for this Medicare coverage.

2) Digital rectal examination including sphincter tone, presence of hemorrhoids, rectal masses
Pelvic examination (with collection of Pap smear) including:

3) External genitalia ( general appearance, hair distribution, lesions)

4) Urethral meatus (size, location, lesions, prolapse)

5) Urethra (masses, tenderness, scarring)

6) Bladder (fullness, masses, tenderness)

7) Vagina (general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele)

8) Cervix (general appearance, lesions, discharge)

9) Uterus (size, contour, position, mobility, tenderness, consistency, decent or support)

10) Adnexa/parametria (masses, tenderness, organomegaly, nodularity)

11) Anus and perineum

When coding for these services the Part B deductible for a screening pelvic examination is waived. Pelvic examinations will be paid under the physician fee schedule, and coders should use the HCPCS code G0101. Medicare allows you to code for the collection of the Pap smear specimen at the same visit if this is the year the patient is eligible for coverage. The code for this service is Q0091. A diagnosis code of V76.2 must be linked to both the G and Q code.

If the provider has performed other preventive services at the same visit that are not covered by Medicare (such as record history, patient counseling, examination of additional organ systems or body areas) this can be billed to the patient. To do this, use the preventive medicine code 99387 or 99397 with a reduced services - 52 modifier.