Ob-Gyn Coding Alert

You can use modifier -76, but be careful reporting dx codes

You know that Medicare won't pay for Q0091 more than once in a 24-month period for low-risk patients, but Medicare's been doling out reimbursement for it anyway. Until the correction takes place on July 1, you still have to refund Medicare.

Be Wary of Reimbursement for Q0091 and Not G0101

When you report Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) and G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) for a low-risk Medicare patient's annual exam, you shouldn't receive reimbursement for either code in a non-covered year.

That hasn't been the case, however. "I noticed Medicare was paying for Q0091 but not G0101 on the 'off' year for low-risk Medicare patients," says Arlene Ferguson, CPC, insurance specialist with Tacoma Women's Specialists in Tacoma, Wash.

If you were confused by the incorrect payment for Q0091, you weren't alone. "We thought there might have been a policy change we missed, although we couldn't find one," says Cindy Foley, billing manager at Upstate Gynecology Group PC in Syracuse, N.Y.

You probably reread the Medicare guidelines stating that reporting Q0091 and G0101 for low-risk patients shouldn't be paid, but pointing that out to insurers may have fallen on deaf ears.

"I started making calls to National Heritage back in May 2003 and tried to explain to them that they should be paying Q0091 once every two years for low-risk patients," asks Christine Dubois, CPC, the coding coordinator and compliance office for Western Mass Physician Associates in Holyoke, Mass. "I even faxed them the Medicare manual to show them that they're paying more money than they should."

Thankfully, Medicare has finally noticed this discrepancy, hence the new transmittal 440 (Editor's note: You can read the transmittal in its entirety at URL www.cms.hhs.gov/manuals/pm_trans/R440CP.pdf.) 
 
How to Use Modifier -76

If your ob-gyn performs a routine Pap smear on a Medicare patient and sends the specimen to the lab, but a repeat Pap is required because the lab informs you that the specimen is inadequate for a determination, you can report Q0091 again but you must append modifier -76 (Repeat procedure by same physician) starting July 1, 2005. This modifier will bypass the frequency edits, and you'll receive payment for the repeat Pap smear.

However, when you have this situation, you've got to watch out for the diagnosis code. You know that if the patient needs to come back for a repeat Pap smear because the first one was insufficient, ICD-9 mandates that you should use 795.08 (Unsatisfactory smear) - but we're talking Medicare.

For Medicare, you can submit a second sample in the same year with Q0091 and modifier -76 and not be subject to the frequency edits, but the diagnosis code for the resubmission is V76.2 (Special screening for malignant neoplasms, cervix), V76.47 (Special screening for malignant neoplasms, vagina), or V76.49 (Special screen for malignant neoplasms, other sites). You would not use V72.31 (Routine gynecological exam), because the ob-gyn isn't performing a full gynecological exam.