Ob-Gyn Coding Alert

As reported in the April 1997 issue of OCA (pages 6-7), Medicare now covers a screening PAP with pelvic exam and clinical breast exam once every 3 years. According to Melanie Witt, program manager for ACOGs department of coding and nomenclature, this new coverage and reimbursement has raised many questions for ob/gyn practices. Witt points out that according to HCFA guidelines this service should be billed to Medicare using G0101 rather than an E/M code, and the service will be priced at the rate for a level 2 established patient visit. HCFA has stated they intend to allow both Q0091, collection of specimen, and G0101, cancer screening and pelvic and breast exam, to be coded for the same encounter (assuming that Medicare has not paid for a screening pap smear in the last 3 years). The ICD-9-CM code that will be accepted by the Medicare carrier for both Q0091 and G0101 is V76.2, special screening for malignant neoplasm of the cervix. The Medicare deductible is waived for the screening pelvic exam.

Part of the confusion comes because the only currently accepted ICD-9-CM code for a screening pelvic exam (V76.2) does not represent accurate coding. In addition, using the currently required V76.2 with the HCPCS code for collection of the specimen when the patients uterus and cervix are absent represents incorrect coding. According to the NCHS ICD-9-CM Coordination and Maintenance Committee, the correct code for screening for vaginal cancer in the asymptomatic patient without prior cancer is code V76.49. If you do not use the ICD code that is accepted by Medicare, however, the services you bill will not be reimbursed. As it stands it will be up to the physician to decide which way to code for these services. However, correct coding is also important, Witt reminds and states that ACOG is currently working with HCFA on refining these rules to be consistent with correct coding practices.

As reported in the April issue of OCA Medicare requires the following to be examined in order to bill for a screening pelvic exam with clinical breast exam (G0101):

Breasts:

Inspection and palpation of breasts for masses or lumps, tenderness, symmetry, or nipple discharge.

Pelvic area:

Perform and Document 6 of the following 10 elements:

-- Digital rectal examination including sphincter tone, presence of hemorrhoids, and rectal masses. Pelvic examination (with or without specimen collection for smears and cultures) including:

-- External genitalia (e.g., general appearance, hair distribution, or lesions)

-- Urethral meatus (e.g., size, location, lesions, or prolapse)

-- Urethra (e.g., masses, tenderness, or scarring)

-- Bladder (e.g., fullness, masses, or tenderness)

-- Vagina (e.g., general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, or rectocele)

-- Cervix (e.g., general appearance, lesions, or discharge)

-- Uterus (e.g., size, contour, position, mobility, tenderness, consistency, descent, or support)

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