Ob-Gyn Coding Alert

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.

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.

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 or support)

- Adnexa/parametria (for instance, masses, tenderness, organomegaly or nodularity)

- Anus and perineum.

Editor's Note: For more information, go to URL: http://www.cms.hhs.gov/transmittals/downloads/R1541CP.pdf.

Applying the new CMS guidance and overlooking Q0091 could mean you-re setting your claim up for a denial.

Scenario: A Medicare patient requests that your physician perform only a Pap smear during an exam. What should you do?

Solution: You can bill Q0091 only, but you can't report V72.31 (Routine gynecological examination) because the physician didn't conduct a complete exam. Instead, you should report V76.2.

Watch out: Sometimes, the lab determines that a Pap smear is insufficient for evaluation, and the physician must obtain a second specimen before the frequency limitation period of one or two years is up. That's when you need to use modifier 76 (Repeat procedure by same physician) to bypass the frequency edits for Q0091.

You should always get the patient to sign an advance beneficiary notice (ABN) when the physician performs a Pap smear sooner than the frequency limitations allow -- or if the patient doesn't remember when her last Pap smear occurred -- because Medicare will deny the claim.

The ABN indicates that the patient is responsible for the portion of the bill Medicare doesn't pay, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, CPC-EMS, RCC, CodeRyte coding analyst and coding review teacher.

Tip: Use modifier GA (Waiver of liability statement on file) on the claim to indicate you have the signed ABN.

Did you know? You can report a new or established patient E/M code (99201-99215) in addition to both G0101 and Q0091, provided the physician documents a separate and distinct E/M service. In this case, attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code. You can bill G0101 on the same date as a screening Pap smear.

Example: The physician performs a well-woman exam for a Medicare patient, but also evaluates and manages the patient's ongoing dysfunctional uterine bleeding. For this service, you-ll report G0101, Q0091, and an E/M service code (99201-99215) with modifier 25 appended.