Ob-Gyn Coding Alert

Question: I work in an oncology/gynecology practice, and we have several Medicare patients whom our ob-gyn sees for yearly pelvic exams due to current or prior breast cancer. Some of the meds they take can cause cervical cancer, so the doctor wants them to have a pelvic. Because we were "screening" for the cervical cancer, I thought we could bill this as preventive. Therefore, I have always billed 9939x, and of course we get lots of complaints. A co-worker says if this is the only reason for the yearly pelvic, I could actually be billing 9921x instead.

Colorado Subscriber

Answer: You are talking Medicare here, not a commercial payer.-Medicare rules dictate that a patient is not at high risk for developing vaginal or cervical cancer with a diagnosis of history (Hx) of breast cancer (V10.3, Personal history of malignant neoplasm; breast).-

Under Medicare rules, if you do the annual Pap because the MD suspects she has cervical cancer due to her history of breast cancer, this service is a diagnostic Pap, not a screening Pap. Medicare will continue to pay for a screening low-risk Pap on a patient with an Hx of breast cancer every two years, but not yearly Paps. When billing for a screening Pap, you-ll receive reimbursement for Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) every two years.

But if you bill Medicare a problem E/M for following the breast cancer and the reason you are doing the Pap smear is for the breast cancer Dx, then Medicare will not pay you for collecting the specimen. Medicare will only pay for the E/M visit.-

For example, 99212 (Office or other outpatient visit for the evaluation and management of an established patient ...) carries 1.03 relative value units (RVUs), unadjusted for geography. That translates to about $38 for this visit.

If the ob-gyn sees the patient for a preventive service and collects the Pap for the breast cancer history, you can bill Medicare in the off year. You would report only the E/M representing only that service that surrounds the taking of the Pap. The rest of the visit the patient will pay for as a noncovered preventive service. In other words, you-ll charge 99397 (Periodic comprehensive preventive medicine ...) to the patient, and submit Q0091 and G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) to Medicare.