Ob-Gyn Coding Alert

Question: How can I get paid for a new patient office visit if I am also billing Q0091 to Medicare? Our physician saw a new patient who had not had a Pap smear for several years. So the doctor obtained a thin prep, and we billed Q0091 and 99203.


Arizona Subscriber

Answer: If the E/M service is unrelated to the purpose of the screening Pap smear, you will need to add 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 E/M code you are billing. Keep in mind: The only way you can report the Pap and pelvic codes with 99203 is if the patient presents with a problem that needs to be evaluated. Code 99203 (Office visit ...) is not a substitute for the rest of a preventive exam (which Medicare does not cover).

Because this is a Medicare patient, you need to ask why are you not also billing G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) for the pelvic/breast exam.

The codes for the covered Medicare exam are G0101 for the pelvic and breast exam and Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) for the collection of the Pap specimen in the year Medicare covers it.

The G code does not include taking history or counseling--only the physical exam and those elements Medicare rules describe. The patient must pay for the non-covered part of the exam. But remember to get her to sign an advance beneficiary notice in case this is not the year Medicare covers the pelvic exam or Pap. If the patient does not sign an ABN (but you signify this by adding modifier GA, Waiver of liability statement on file, to the G and Q codes) and Medicare denies these services, you cannot collect the denied amount from the patient.