Pediatric Coding Alert

Question: Many of our female teenage patients prefer to return to see our female pediatrician for their Pap smears. The patients' regular male pediatrician has already performed the rest of the preventive medicine service's physical examination. Can I use G0101 for the gynecological exam?

California Subscriber

Answer: No, G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast exam) is a Medicare code that allows a physician to carve out this service's covered portion from the noncovered preventive medicine service for a female beneficiary. Normally, the gender-appropriate portion of the preventive medicine service, such as 99394 (Periodic comprehensive preventive medicine ... adolescent [age 12 through 17 years]) includes the breast and pelvic exam.

You could use modifier 52 (Reduced services) on each of the preventive medicine service portions you are performing and reduce your charges accordingly. Explain in the cover letter that the first 99394-52 represents the preventive medicine service without the female well exam performed by Pediatrician A, a male, and that the second 99394-52 is for the breast and pelvic exam with Pap smear that Pediatrician B, a female, provided. But the insurer may still misallocate the patient with two annual checks.

Best bet: Give patients the option up-front to schedule the whole preventive medicine service with the female pediatrician. When female teenagers or their guardians call in to schedule their preventive medicine services, have the schedulers explain what the visit will entail.