Ob-Gyn Coding Alert

Question: We charge a set fee for preventive care for every patient, then bill G0101 and Q0091 when it is a Medicare patient. The patients sign a waiver, and if Medicare does not pay for the services, the patient does. Can we bill Q0091 in the "off" year? What if Medicare pays that amount and denies G0101?

Illinois Subscriber

Answer: It appears that you bill all patients the same amount for the preventive service, tack on the G and Q codes and send it to Medicare. This is incorrect because the G and Q services are normally a part of the preventive service each year; in the covered year, these codes would be "carved out" from the preventive service.
 
If you think of the annual well-woman exam as a pie and the portions that Medicare sometimes pays for as slices of that pie, the problem may seem clearer.
 
You bill the patient for the part of the pie you know is hers (the noncovered portion) and then bill Medicare for the two slices you hope Medicare will pay for.
 
If they deny either one of those "slices," you ask the patient to pay for it; hence, the term "carving out."
 
Let's say your normal fee for a total preventive service is $150 for every patient, but you will be asking Medicare to pay for a portion of that preventive service.
 
You must subtract the allowable for the potential Medicare portion from your $150 fee to determine the patient's responsibility.
 
If you are not collecting up front from the patient for the noncovered portion and are waiting for Medicare to deny the service so you can try to get secondary to cover it, you will be sending all the codes to Medicare as follows:

 

993xx-52-GY (Initial or periodic comprehensive preventive medicine ; reduced services; item or service statutorily excluded or does not meet the definition of any Medicare benefit) ($150 - $35.48 - $38.37 = $76.15)

 

G0101-GA (Cervical or vaginal cancer screening; pelvic and clinical breast examination; waiver of liability statement on file) ($35.48, per the current Medicare fee schedule)

 

Q0091-GA (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory; waiver of liability statement on file) ($38.37, per the current Medicare fee schedule).
 
If Medicare denies one or both of the G and Q services, you can add that amount back into what the patient owes you. The bottom line here is that you receive in total from all sources only the amount for the preventive service because all of the services you are billing to different payers (i.e., patient and Medicare) are part of that total preventive service.