Primary Care Coding Alert

When your FP provides a well-woman examination to a Medicare patient, be sure to use a combination of CPT and HCPCS codes to receive the fullest possible reimbursement.

Filing these claims also involves carving out covered portions of the preventive medicine code to ensure claim compliance. Check out this plan for filing well-woman exams for your Medicare beneficiaries.

For the preventive examination, you-ll choose one of the following codes, says Jan Allen, claims and accounts receivable manager for a three-physician practice in Santa Paula, Calif.

- 99387 -- Initial comprehensive preventive medicine evaluation and management of an individual including an age- and gender-appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization(s), laboratory/diagnostic procedures, new patient; 65 years and older

- 99397 -- Periodic comprehensive preventive medicine re-evaluation and management of an individual including an age- and gender-appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization(s), laboratory/diagnostic procedures, established patient; 65 years and older

(Note: You-ll use 99387 or 99397 for beneficiaries entitled to Medicare on the basis of age. But patients who receive Medicare due to disability or kidney transplant, for example, may be younger than 65. In those cases, the physician might choose a different preventive medicine code reflecting the patient's age -- such as 99396 if it's an established patient 40-64 years of age.)

However, Medicare does not cover these routine exams. For that reason, your practice will have to carve out the covered portions and not charge the patient the entire preventive care fee. To arrive at the amount the practice can collect from the patient:

- take the billing price (meaning the usual charge) for the preventive care exam,

- subtract the billing prices (meaning the usual charges) for a breast and pelvic exam (G0101, Cervical or vaginal cancer screening; pelvic and clinical breast examination) and collection of a screening Pap smear (Q0091, Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) and

Result: Charge the patient that amount.

For example, if the practice usually charges $150 for a preventive care exam, $50 for G0101 and $25 for Q0091, the practice can collect $75 from the patient in addition to any coinsurance owed on the breast and pelvic exam or screening Pap smear collection.

Also, remember to append modifier GY (Item or service statutorily excluded, does not meet the definition of any Medicare benefit or for non-Medicare insurers, is not a contract benefit) to the CPT code.

This modifier will allow Medicare to formulate the amount the patient owes on the explanation of benefits (EOB). Suppose your FP provides a routine exam to a 68-year-old established Medicare patient. On the claim, report 99397-GY for the service.

For patients with Medicare coverage, you-ll be able to report pelvic/breast exams and Pap smears separately, in addition to the CPT code for the preventive medicine visit. Report breast/pelvic exams with G0101, Allen says. If the FP also obtains a screening Pap smear during the encounter, report that service with Q0091, she says.

Suppose the FP provides a complete well-woman exam, with breast/pelvic exam, and screening Pap smear for a 68-year-old new Medicare patient. On the claim, you-d report the following:

- 99387-GY for the general exam

- G0101 for the breast/pelvic exam

- Q0091 for the Pap smear.

You-ll need to observe strict qualification guidelines for your patients who receive well-woman exams and screening Pap smears in the same session.

Medicare has set risk categories for patients receiving screening Pap smears: average-risk patients are eligible for the test every two years, while those at high risk can have one annually.

For many average-risk patients, you-ll attach V76.2 (Special screening for malignant neoplasms; cervix) to Q0091 to explain the reason for the test, says Sean Weiss, CPC, CPC-P, CMPE, CCA-P, CCP-P, senior partner at The CMC Group LLC in Atlanta.

(Note: Medicare covers breast/pelvic exams once every two years for its average-risk patients; patients with certain risk factors may receive a covered breast/pelvic exam more frequently.)

According to chapter 18 of the Medicare Claims Processing Manual, Medicare will also accept these diagnoses for average-risk Pap patients:

Here are Medicare's high-risk factors for cervical and vaginal cancer:

- Early onset of sexual activity (under 16 years of age; V69.2, High-risk sexual behavior).

- Multiple sexual partners (five or more in a lifetime, V69.2).

- History of a sexually transmitted disease (including HIV infection, V08, Asymptomatic human immunodeficiency virus [HIV] infection status; or 042, Human immunodeficiency virus [HIV] disease). For sexually transmitted diseases other than HIV, use the appropriate diagnosis code reflecting exposure to or personal history of the disease, such as V01.6 (Contact with or exposure to communicable diseases; venereal diseases).

- Fewer than three negative or any Pap smears within the previous seven years (795.0x, Abnormal Papanicolaou smear of cervix and cervical HPV; V15.89, Other specified personal history presenting hazards to health; other).

- DES (diethylstilbestrol)-exposed daughters of women who took DES during pregnancy (760.76, Noxious influences affecting fetus or newborn via placenta or breast milk; diethylstilbestrol [DES]).