Ob-Gyn Coding Alert

Question: Our office recently saw a Medicare patient for preventive care. Both a pelvic exam and Pap smear were done, but a breast exam was not performed. How should this visit be coded? Can I also bill for the collection of the Pap using HCPCS code Q0091?

Paula Murphy, of Seaborn M. Hunt, MD
Ocala, Florida

Answer: First, Medicare only covers a screening pelvic/breast exam every 3 years if the patient does not meet the Medicare criteria for being in a high-risk category for annual screening exams. So, you must determine if this is the year that Medicare will reimburse for the screening pelvic exam and screening Pap smear for this beneficiary. If the Medicare benefit for this screening work-up is not covered for the patient this year, the encounter should be billed using the preventive medicine CPT codes 99387 [new patient] and 99397 [established patient]. This is because you will have provided a preventive medicine service and these CPT codes are the correct way to code for the service. Since these codes are excluded from Medicare coverage, the patient may be billed directly for the service. These codes include the breast exam and since it was not performed, the exam for this preventive-medicine visit would be less than the required comprehensive exam dictated by the CPT description of the preventive service. Thus, you would either add a modifier -52 (reduced services) to the preventive code, or you could bill a lower level E/M service as recommended in the AMAs CPT Companion.

If Medicare will be paying for the screening exam this year, similarly, you will have to add a modifier -52 to the G0101 code because you have not performed the required exam elements. Upon receipt of the EOB for this service, if you find that the Medicare carrier has paid you the full allowable, be sure to inform the carrier in writing that less than the required service was provided.

You may bill Q0091 for the Pap specimen collection if Medicare will also cover the screening Pap interpretation this year. If they will not, the collection becomes part of the preventive exam and is not appropriately coded separately.