Ob-Gyn Coding Alert

Question: When a Medicare patient refuses a pelvic exam and the ob-gyn performs only a breast exam, which code should I report? Can I still submit G0101 if there is clear documentation that the patient refused the pelvic exam?

Wisconsin Subscriber

Answer: If the ob-gyn performed only the breast examination, you cannot report G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination). Instead, you should report an E/M service (99201-99205 for a new patient, or 99211-99215 for an established patient) linked to V76.19 (Other screening breast examination). Be sure to get the patient to sign an advance beneficiary notice (ABN) because carriers may not cover this preventive service alone.

If there is a reason other than screening that the patient needs the breast exam every year -- for example, a history of a breast problem -- use that diagnosis (such as V10.3, Personal history of malignant neoplasm, breast) instead of V76.19.