Ob-Gyn Coding Alert

Question: With Medicare allowing annual gyn exams (cervical cancer screenings) every three years, when is it appropriate to use hormone replacement therapy (HRT) as a diagnosis to support a problem visit? There are physicians who dont want a Medicare patient to receive a bill, and as a result typically select an office visit code (99201-99215) to support a problem of HRT. But they dont select V07.4 as a diagnosis. How do you code for this?

New Jersey Subscriber

Answer: Medicare will pay for an annual gyn exam (G0101, cervical or vaginal cancer screening; pelvic and clinical breast examination) and Pap smear (Q0091, screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) every three years. And you can bill separately for an evaluation and management (E/M) visit even when these screening codes are billed as long as the physician has documented a significant and separately identifiable E/M service for a problem.

If this is the year that the screening tests are covered and the patient complains of significant problems relating to menopause, you may be able to meet the criteria for an expanded problem-focused visit (i.e., 99202 or 99213) in addition to the screening because you will not be able to count the same exam elements and history for both the screening and the problem. If this is the year the screening tests are not covered, you may be able to bill Medicare for that portion of the visit that relates only to the problems she is presenting with. You should be wary, however, about billing Medicare for conditions that are not supported by the documentation. That is, most women older than 65 years of age will have atrophic vaginitis, but if the physician is seeing the patient only once a year for this problem and the medical record shows no treatment, this may appear to Medicare to be coding for a preventive service. This is why Medicare rules state very clearly that you can only bill for a service that was medically necessary in the treatment of illness, disease or symptoms.

Local carriers seem to be divided on this subject: Some consider menopause to be a normal process that is preventive in nature. Others believe that if care is given at a visit other than the annual exam for problems with menopause, Medicare would cover the service. Consequently, if this visit is not associated with the yearly exam, but its purpose is to monitor the patient who is taking HRT, then use diagnosis code V07.4 (postmenopausal hormone replacement therapy). If the patient is also having problems with her medication, and if you add a second code to describe what those problems are, chances are good that Medicare will pay for the visit. The level of service, however, must reflect the documented findings and decisions relevant to the complaint or condition of the patient.