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.

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 qualifies on any of those points, she should so indicate, and that will inform the office staff to code V15.89." Once high-risk status has been established per these guidelines, that status will not change for the duration of the patient's care. In other words, the historical factors determining her risk level (e.g., early onset of sexual activity or more than five partners) won't change.
 
Depending on the risk status, the encounter with the patient is billed to Medicare as follows:
 

G0101, linked to V76.2/V76.49 or V15.89, or

Q0091, linked to V76.2/V76.49 or V15.89.

Determining Medicare risk status is fairly straightforward for some patients, especially when their history falls neatly within the risk parameters. The following case study is representative of those patients with a long-term history of abnormal Paps and other diseases or surgeries. Choosing the patient's risk category is not a simple task.
 
A 37-year-old Medicare patient has renal and liver failure due to alcoholic liver disease. The patient, who is on dialysis, presented for a well-woman examination, and her results were normal. Given the severity of the patient's other illness, the coder is confused as to whether the patient is considered high-risk or low-risk according to Medicare's guidelines.
 
"Because the high-risk and low-risk categories refer to the risk of gynecological cancers and not other diseases, this patient is not high-risk by Medicare standards," Stuber says. "The exam would be coded using V76.2." He adds that if the physician rendered any treatment related to the cirrhosis (i.e., tests, counseling with patient), a separate E/M service would be billed to Medicare in addition to the screening exam, and the diagnostic code for that disease (571.2, alcoholic cirrhosis of liver) would be linked to the problem E/M service.
 
"The other factor to keep in mind," Stuber says, "is that the Medicare risk table applies only to women who are past childbearing age." In this case, the patient is 37 and may still be of childbearing age, but the Medicare criteria for this situation involve a history of cancer or other gynecologic problems in the past three years. As a result, regardless of which risk factors are involved, the patient would still not meet the criteria for high risk based on her age.
 
The second case study presents the length of time between the patient's Pap smears as the determining factor in assessing risk.
 
A 62-year-old patient who had a TAH (total abdominal hysterectomy) eight years ago has not had a Pap smear since, though she has had a pelvic examination. Prior to the TAH, she had a history of abnormal Pap smears.
 
Given these circumstances, the patient qualifies as high risk due to her history of abnormal Paps and the absence of a Pap test in more than seven years. The patient is eligible for a screening Pap and a pelvic exam every year.
 
Note: The Pap test is actually a collection of a vaginal vault sample for a Pap interpretation.

The diagnostic code is V15.89, as the patient does not meet the Pap-test criteria. Stuber points out that once the patient has a Pap test, she no longer qualifies as high-risk on the "more-than-seven-years" rule, though she still qualifies under the "absence-of-three-negative-Pap-smears" rule.
 
If over the next three years, however, all of her Pap smears are negative, she will no longer be considered high-risk. After the third negative Pap test and assuming no other risk factors are met, she would be recoded as low-risk. Because she has had a hysterectomy, V76.49 would be appropriate in this case, and she would be eligible for a Pap smear and pelvic exam every two years instead of every year.
 
A third case study shows that even when risk factors are present, choosing the diagnostic code may not be an easy task.
  
A 65-year-old patient has had ovarian and endometrial cancer but has not had any abnormal Pap smears in a few years. She has been coming in for an annual for G0101 and Q0091.
 
There are two choices in this case. If the patient is many years post-cancer (the number of years is not set by Medicare as part of its policy, but would in most cases depend on the physician's judgment), the Pap and pelvic exams can be considered part of a normal screening and may be billed to Medicare once every two years. The other possibility is that the examination and test can be considered a diagnostic Pap and pelvic and billed every year. In the former case, you can bill Medicare using the G and Q codes with a diagnosis of V76.49, because the patient appears to have had a hysterectomy.
 
In the latter case, the G and Q codes no longer apply. When performing a diagnostic service, you should bill an E/M service only, and the diagnosis will be the history of the disease she had. The "once-every-year" Medicare high-risk rule applies only when the patient has one of the listed high-risk criteria. Yet with a history of cancer, a physician may well want to monitor the patient on an annual, rather than biennial, basis.
 
Note: Medicare's rules on the frequency with which G0101 and Q0091 are paid changed as of July 1, 2001. Previously, low-risk-category patients were eligible for a Medicare-reimbursed well-woman exam only every three years. Under the new regulation, the services are now payable every two years. High-risk patients are still eligible once every year.