Ob-Gyn Coding Alert

Coding and reimbursement for Medicare well-woman screening exams is one of the biggest challenges in ob-gyn coding . You must know whether a patient meets Medicare's criteria for "high-risk" or "low-risk." This risk factor determines the frequency with which Medicare pays for well-woman care.
 
Medicare sets parameters as to when a patient is high-risk and eligible for annual well-woman exams, versus when a patient is low-risk and eligible for well-woman exams only once every two years. Although the codes for the exam and Pap smear collection are the same -- 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) -- ascertaining patient risk is essential to proper reimbursement and responsible preventive care.
Risk Codes and Factors
When billing for Medicare well-woman care, use one of three diagnostic codes:
  V76.2 -- special screening for malignant neoplasms; cervix
  V76.49 -- special screening for malignant neoplasms; other sites
  V15.89 -- other specified personal history presenting hazards to health; other.   V76.2 and V76.49, the ICD-9 code selected by Medicare for when the patient no longer has a uterus, are the "low-risk" codes, and V15.89 is the "high-risk" code. For the well-woman exam, high-risk indicates that due to family, personal/social or medical history the patient is at greater risk for developing cervical or other gynecological cancers. It has no bearing on any other health problems the patient may have that are unrelated to her reproductive and sexual history.
 
"There are very specific parameters that allow you to be high-risk and thus receive screening (not diagnostic) Paps, screening pelvic and breast exams every year paid by Medicare," says Harry Stuber, a solo ob/gyn in Cookeville, Tenn. Medicare guidelines have several factors that indicate high risk: 
  Onset of sexual activity under 16 years of age (V69.2, high-risk sexual behavior)

Five or more sexual partners in a lifetime (V69.2)

History of sexually transmitted disease (V13.8, personal history of other specified diseases)

Absence of three negative Pap smears (795.0, abnormal Pap smear) 

History of HIV (V08, asymptomatic HIV status, or 042, HIV)  

Absence of any Pap smears within the previous seven years. No specific ICD-9 code exists for this, but V15.89 may be acceptable by itself. You may need to submit documentation with the claim

Prenatal exposure to DES (760.76, DES affecting fetus via placenta or breast milk) (commonly referred to as DES daughter).

These criteria apply to women who are no longer of childbearing age. The risk status is determined largely through the interview form the patient completes at the outset of her treatment with the physician. "Some practices literally list them on a form," Stuber says, "explaining to the patient that if she [...]