Ob-Gyn Coding Alert

Question: After review requests from Medicare, several of our claims have been denied for 99212, 99213 and 99214 evaluation and management (E/M) codes that have been submitted for visits. For example, a patient is seen for a six-month postsurgery follow up for second-degree prolapsed uterus, cystourethrocele and vault prolapse. A routine annual exam cannot be billed because a full annual examination was not done. Another problem we are having with Medicare is patients who are referred by their oncologist for six-month examinations with Pap smear for previous history of breast cancer (on Tamoxifen). What is the best code to use for these types of service?

Michelle Vasquez
Utica, N.Y.

Answer: This question has several different parts, but all center around Medicare policy. First, Medicare will usually reimburse for follow-up visits after surgery when they are not part of the global surgical package. Surgery for the correction of a second-degree prolapsed uterus (618.1), cystourethrocele (618.0) and vault prolapse (618.5) involve procedures with a 90-day follow-up period. If you are seeing them six months after the surgery, then the E/M services should not be denied for that reason. But diagnosis coding may be the problem here. A follow-up visit after surgery has corrected the problem can only be coded using V67.0 (follow-up examination following surgery). Each carrier, however, is allowed to make up its own rules about follow-up care for a treated condition, and some may deny the claim because the condition is cured. Remember that Medicare is supposed to pay only for the treatment of illness, disease and symptoms with some minor preventive screening exceptions. In your case, if you are using V67.0, you need to check directly with the carrier about its rules regarding follow-up care after the global period has been completed.

As for your second question about the limited exam, Medicare does not pay for a full annual exam under any circumstances. Rather, it pays for the physical examination of the breasts and the genitourinary tract once every three years for a patient who is not considered high risk (so indicated by using the diagnosis code V76.2 [special screening for malignant neoplasms, cervix] or V76.49 [special screening for malignant neoplasms, other sites] when the patient has no uterus or cervix) and once every year in a high-risk patient (indicated by using the diagnosis code V15.89 [other specified personal history presenting hazards to health, other]). This is billed to Medicare using G0101 (cervical or vaginal cancer screening; pelvic and clinical breast examination). If you collect a Pap smear specimen at that same visit and the patient is eligible for a screening Pap test, you may also bill Medicare Q0091 (screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory). You would then bill the patient for any noncovered preventive services that might have been performed that day.

You could also bill Medicare for any significant problems that were encountered and documented during the visit. This means the physician has separately documented at least a level-three E/M service (99213-99215). The E/M service, of course, would require the addition of modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) before Medicare would consider payment. But as in the first example, if the exam was purely for follow-up to surgery following the global period, bill it using either a cancer code (should the physician still feel the patient has cancer) or a history-of-cancer code along with the V code for follow-up exam following surgery.

Your third question involves billing for an encounter when you are asked to examine a patient and collect a Pap smear specimen because the patient is taking Tamoxifen. You can code the E/M service for this visit (but not the Pap smear collection code Q0091) using a diagnosis of V58.69 (long-term [current] use of other [high-risk] medications). Note that Q0091 is used for collecting a specimen for a screening Pap smear, not a diagnostic specimen. When a patient is taking Tamoxifen, the Pap test will be diagnostic, not screening, under Medicare guidelines.

The above questions were answered by Melanie Witt, RN, CPC, MA, former program manager for the American College of Obstetricians and Gynecologists (ACOG) department of coding and nomenclature and an independent coding educator.