Ob-Gyn Coding Alert

Question: A Medicare patient is seen for menopausal symptoms and postmenopausal bleeding. E/M codes (99201-99215) are used for billing. At the same time, we do a breast and pelvic exam and obtain a Pap smear. When we add Q0091 and G0101 to the E/M codes, we receive denials. Why can't we bill these codes together?

California Subscriber

Answer: The Medicare rules for billing a problem E/M service and the screening pelvic and Pap-smear collection on the same day are very straightforward. Medicare began paying for a problem E/M service and G0101 (cervical or vaginal cancer screening; pelvic and clinical breast exam) in January 1999. In April 1999, it allowed Q0091 (screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) to be billed with a problem E/M service also.  

However, the rules state that the problem E/M service must be significant and separately identifiable from the screening breast, pelvic exam and Pap-smear collection. Therefore, you may only bill an E/M service when you 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 code, and the documentation for the problem exam may not count the elements of the G0101 examination twice but must stand on its own merit at the level being billed.
 
Some carriers have the policy that if the E/M service being billed is only a level-two service, a significant service has not been performed and may not be paid in this instance. And the diagnosis for the E/M service will be different from that linked to the G and Q codes. These codes require that a diagnosis code (V76.2, special screening for malignant neoplasms, cervix) be used in order to receive payment for the patient in a low-risk category, e.g., when Medicare pays only for the screening exam and Pap-smear collection once every two years.
 
If the patient is in a high-risk category, indicate a diagnosis of V15.89 (other specified personal history presenting hazards to health; other) and bill Medicare for these screening tests each year. To qualify the patient as  high-risk, one of the following must be documented in the patient's chart: onset of sexual activity under age 16; five or more sexual partners; history of STDs or HIV; absence of three consecutive negative Paps, no Pap-smear interpretation in the last seven years, or prenatal exposure to DES.