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)

-- Adnexa/parametria (e.g., masses, tenderness, organomegaly, or nodularity)

-- Anus and perineum

Medicare will only reimburse for the screening pelvic examination on an annual basis in two circumstances:

1. The woman is of childbearing age and cervical or vaginal cancer is present (or was present) or abnormalities were found in the preceding 3 years

2. The woman is in a high-risk category. High-risk for Medicare includes one or more of the following factors:

Onset of sexual activity under 16 years of age (ICD-9-CM V69.2, high-risk sexual behavior);

Five or more sexual partners in a lifetime (ICD-9-CM V69.2);

History of sexually transmitted disease (ICD-9-CM V13.8, personal history of other specified diseases of the genital system);

Absence of 3 negative pap smears (ICD-9-CM 795.0, abnormal pap smear);

History of HIV (ICD-9-CM V08, asymptomatic HIV status or 042, HIV)

Absence of any pap smears within the previous 7 years (no specific ICD-9-CM code exists for this, but V15.89, other specified personal history presenting hazards to health, may be acceptable. You may need to submit documentation with claim); or

Prenatal exposure to DES (ICD-9-CM 760.76, DES affecting fetus via placenta or breast milk)

Tip: Although each factor has a specific ICD-9-CM code (as noted above), the Medicare carrier will only accept the diagnosis code V15.89 on the claim form when you are billing for an annual pelvic exam. The code V76.2 would not be reported since this is a high risk patient, not an asymptomatic one.

Additional Services Not Covered

An additional concern arises from the fact that Medicare has stated they will not reimburse G0101 or Q0091 with any other covered E/M service. So if the patient comes in for cancer screening or pelvic and breast exam and in addition the physician provides services for a problem this leaves the physician with the decision of billing for the screening pelvic exam or the problem E/M service at the appropriate level. You could have the patient come in another day -- but be sure the physician is sure this course of action is good medicine and what is best for the patient.

Comprehensive Preventive Exam Coding

This new Medicare reimbursement for the screening of cervical and vaginal cancer and pelvic and breast exam does not include examination of any area other than the breasts and genital area. It does not include history taking, patient counseling about current asymptomatic problems (e.g., menopause, osteoporosis, diet, etc.) or medical decision-making (e.g., renewal of prescriptions, evaluating a minor problem at the encounter). Therefore if the physician performs a comprehensive preventive annual examination that included additional work beyond that covered by Medicare, coding will be different. The non-covered portion of the exam may be carved out and billed to the patient using an appropriate preventive services code with a modifier -52 for reduced services (e.g., 99397-52). The patient would be billed the difference between the fee for the non-covered preventive service and the amount allowed by Medicare for the screening pelvic exam plus pap smear collection (if billed).