Ob-Gyn Coding Alert

Question: A Medicare patient is seen for menopausal symptoms and post-menopausal bleeding. Evaluation and management (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 adding Q0091 and G0101 to the E/M codes we get denials. Why cant we bill these codes together?

Hratch Pezeshkian
Glendale, Calif.

Answer: The Medicare rules for billing a problem E/M service and the screening pelvic and Pap smear collection codes on the same day are 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, and in April 1999 allowed Q0091 (screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) also to be billed with a problem E/M service. But the rules state that the problem E/M service must be significant and separately identifiable from the screening breast and pelvic exam and Pap smear collection. Therefore, you may bill an E/M service only when you have attached 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. The documentation for the problem exam may not count twice the elements of the G0101 (gynecology) examination. Instead, the physician would need to document additional history and medical decision-making. This documentation would determine the additional history and medical decision-making and determine the E/M level to which the -25 modifier is added to show it was significant and separately identifiable from the other services billed to Medicare that day.

Some carriers have established the policy that if the E/M service billed is only a level 2 (99202, 99212) service, a significant service has not been performed and may not be paid in this instance. In addition, the diagnosis for the E/M service will be different from that linked to the G and Q codes. These codes require that V76.2 (special screening for malignant neoplasm, cervix) be used to receive payment for the patient in a low-risk category (that is, when Medicare only pays for the screening exam and Pap smear collection once every three 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 you can bill Medicare for these screening tests each year. To qualify as high-risk, one of the following needs to be documented in the patients chart:

onset of sexual activity under the age of 16;

five or more sexual partners;

history of a sexually transmitted disease (STD) or HIV;

absence of three consecutive negative Paps;

no Pap smear interpretation in the last seven years; or

prenatal exposure to (diethylstilbestrol) DES.

Source for Reader Questions is Melanie Witt, RN, CPC, MA, the former program manager for the American College of Obstetrics and Gynecology (ACOG) department of coding and nomenclature and an independent coding educator.