Ob-Gyn Coding Alert

Here's your one-stop guide to appending modifiers 76, GA and 25 You can still report G0101 even when your ob-gyn doesn't perform a breast exam, thanks to a new CMS clarification. To capture all allowed well-woman exam components without overcoding, you-ll need two codes. You, however, may have to rely on one code when your ob-gyn performs only the Pap smear portion. You-ll also need to append a modifier when your ob-gyn manages the patient for an unrelated problem in addition to a well-woman exam or provides this exam sooner than frequency limitations allow. Our experts break down what you need, and what you should report in each case. First, Code the Whole Medicare Well-Woman Picture When the physician provides complete well-woman exams (a pelvic exam, breast exam and Pap smear) for Medicare patients, report G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) and Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory). You can link these codes to diagnosis codes such as V76.2 (Special screening for malignant neoplasms; cervix) for low-risk patients or V15.89 (Other specified personal history presenting hazards to health; other) when the patient has gone seven years without a Pap smear, for instance, for high-risk patients, says Pat Larabee CPC, CCP, a coding specialist at InterMed, a multispecialty healthcare network in South Portland, Maine. For G0101, Apply This New CMS Clarification What's new: The breast exam does not need to be one of the seven elements in the following list. Previously, CMS organized the bulleted elements in a way that suggested that the ob-gyn is required to give a breast exam. Also, G0101's definition includes a clinical breast exam. Therefore, most coders believed that a breast exam must be one of the elements. Thanks to this clarification, you can see this is not the case. Heads up: According to CMS Transmittal 1541, when your physician performs a screening pelvic examination (with or without specimen collection for smears and cultures, and including a clinical breast examination), the exam needs to include at least seven of the following eleven elements: - Inspection and palpation of breasts for masses or lumps, tenderness, symmetry or nipple discharge - Digital rectal examination including sphincter tone, presence of hemorrhoids, and rectal masses - External genitalia (for example, general appearance, hair distribution or lesions) - Urethral meatus (such as size, location, lesions, or prolapse) - Urethra (for instance, masses, tenderness or scarring) - Bladder (for example, fullness, masses or tenderness) - Vagina (e.g., general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele or rectocele) - Cervix (for example, general appearance, lesions or discharge) - Uterus (such as size, contour, position, mobility, tenderness, consistency, descent [...]