Part B Insider (Multispecialty) Coding Alert

Use These Strategies to Avoid Double-Billing, Upcoding

When a patient comes in for a routine annual or biannual Pap smear and pelvic exam, other problems may arise. But when should you bill for those added claims?
 
With a non-Medicare claim, there's a simple rule of thumb: If more than 50 percent of a visit is taken up with an annual exam, just bill for the annual exam, says Philip Eskew, medical director for women and infant services with St. Vincent Hospital in Indianapolis.
 
But since Medicare only pays for a breast exam, Pap smear and pelvic exam, not the rest of an exam, the situation is less clear-cut. The general principle remains the same, however: Resist the temptation to upcode a routine screening to something else unless a serious problem turns up, Eskew insists.
 
There are two situations in which visits for routine Pap smears and pelvic exams could turn into something more serious, notes consultant Melanie Witt in Fredricksburg, Va. In both cases, it's important to provide enough documentation to support the evaluation and management claim.
 
1) A menopausal patient comes in for a screening exam and complains of an unrelated problem, such as hot flashes, sweating and lack of sleep. The doctor talks to her about the unrelated problem. In this case, the doctor can still bill G0101 for the pelvic exam, but should document the E/M claim carefully.
 
2) A patient comes in for an exam and complains of symptoms that could indicate a prolapse. In this situation, the pelvic exam turns into a response to the problem the patient has presented. The doctor should bill for the E/M service but not for the pelvic exam, because it's related to the E/M. The doctor can still bill Q0091 for a screening Pap smear separately, notes Witt.
 
You should bill anything that requires a history, examination or medical decision-making during a screening visit as a 99212-99214 E/M service, with the -25 modifier, Eskew advises. 
 

"I have a lot of patients who will ask me something about what I'm prescribing, whether it's a medication for their bones or a hormone," Eskew says. "I don't bill them separately just because they asked a question." Don't bill for a separate E/M service unless the physician has done significant work.