Ob-Gyn Coding Alert

Question: What is the correct way for an ob-gyn to bill Medicare for an annual exam (Pap, pelvis and breast exam)? Should I use 99387/99397 with G0101? Or should I bill for the office visit 99201-99215 with G0101? The ob-gyn is not now managing any additional acute or chronic conditions. 


Alabama Subscriber

Answer: The correct way, in the absence of evaluation of problems, is to bill the patient for the non-covered portion of the exam (99387, New patient preventive medicine service -; 65 years and older; or 99397, Periodic comprehensive preventive medicine reevaluation and management -; 65 years and older) and bill Medicare using G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) and Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory).

Important: If you need to submit the non-covered code to Medicare to get a denial so the patient's secondary insurance will pick it up, you should add modifier GY (Item or service statutorily excluded, does not meet the definition of any Medicare benefit or for non-Medicare insurers, is not a contract benefit) to that code. Also, don't forget modifier GA (Waiver of liability statement on file) when the patient signs an advance beneficiary notice (ABN).

Altogether, your claim would look like this:

- 99387-GY (billed to Medicare to get a denial)
- G0101-GA (ABN signed in case Medicare does not cover this at the time of service)
- Q0091-GA (ABN signed)

To estimate the patient's payment, you subtract the Medicare allowable for G0101 and Q0091 from your normal fee for 99387. Note: You cannot receive greater payment for these three components of the annual than your normal fee for the annual. If Medicare denies the G or Q code, you add it back in, and that is additional money owed to you by the patient.