Primary Care Coding Alert

When billing for a preventive medicine service, gynecological examination and Pap smear, family physician (FP) coders can sacrifice up to $75 in revenue for each case, leaving many practices not feeling good. But you may find an easy remedy for your woes: Know what the codes include, serve thy payer, and explore HCPCS level-two codes.

With various insurers requiring a multitude of methods to report an annual gynecological examination, you face a real challenge, says Cathy Gasiewicz, RHIT, system compliance coordinator at Botsford Clinic in Farmington Hills, Mich. But, what many FP coders overlook are the HCPCS level-two national codes, which include G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination), Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory), S0610 (Annual gynecological examination; new patient) and S0612 ( established patient). Although Medicare does not cover the S codes, the Blues float away with covered alternatives.

To navigate through the coding maze, you should understand why so many options exist. CPT does not provide a separate code for a gynecological examination, which many FPs provide as part of a preventive medicine service (99381-99397) for a female patient. Therefore, you may fall into the trap of failing to separately code a breast and pelvic exam and Pap smear when it is appropriate to do so. Each of these services deserves separate coding for Medicare purposes. Failing to do so can sacrifice almost $75 in Medicare revenue, based on a $36 breast and pelvic exam fee and $39 Pap payment (the Medicare Physician Fee Schedule grants 0.97 relative value units to G0101 [0.97 x 36.79 = 35.69]) and 1.06 RVUs to Q0091 [1.06 x 36.79 = 39.00]). (Your physician may want to set separate fees forthese services to facilitate billing for them separately, when appropriate.)

Part of this undercoding loss comes from the ambiguity implied in the preventive medicine codes. Codes 99381-99397 refer to a comprehensive preventive medicine E/M. A comprehensive preventive medicine E/M is not, however, the same as the comprehensive examination required in E/M codes 99201-99350, CPT states. Codes 99381-99397 instead reflect an age- and gender-appropriate history/exam, which creates some variability, says Kent Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians in Leawood, Kan.

To bill these additional services, you must follow each payer's rules. So let's look at three common guidelines: Medicare, Blue Cross/Blue Shield (BCBS), and other third-party payers.

The most copied insurer, Medicare, requires G0101 for breast and pelvic exams and Q0091 for the Pap smear. Medicare allows billing both services at a frequency based on the patient's risk factor. For patients who are at normal risk, Medicare will cover the exam and screening every two years. If the patient meets Medicare's high-risk criteria, such as early sexual activity or abnormal Pap smears, the carrier will cover annual exams.

Now, the trick with Medicare is that it does not cover the preventive medicine exam. For example, a normal-risk patient who has not received a pelvic or breast exam or a Pap smear in two years presents for a well visit. The FP performs a preventive medicine exam, a pelvic and breast exam, and a Pap smear. You can bill Medicare for the add-ons only (G0101, Q0091), rather than the preventive medicine service.

But that doesn't mean you have to sacrifice the preventive medicine exam fee. You can still report 99381-99397 appended with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to indicate a significant, separately identifiable E/M service. In fact, your FP may bill the patient for the exam at the time of service. You do not need an advance beneficiary notice (ABN) because Medicare does not require a waiver for services that it never covers. You should append modifier -GY(Item or service statutorily excluded or does not meet the definition of any Medicare benefit) to the preventive exam, however, to indicate a noncovered service.

On the other hand, you will need to obtain an ABN when the patient receives a Pap smear in the off year (non- high-risk patient when the FP performs the exam annually). Append modifier -GA (Waiver of liability statement on file) to Q0091 to indicate that you expect Medicare to deny the procedure as not medically necessary and that you obtained an ABN. After Medicare denies the service, you can bill the patient for the Pap smear.

If the FP doesn't know if he or she is providing the service in the off year, you should bill Q0091-GA. Medicare will then determine if the patient qualifies for coverage and will pay or reject the claim accordingly.

Although Medicare uses G0101 for a pelvic and breast exam, the Blues previously required S0610 or S0612 for a routine gynecological exam. "The Blues are now paying for annual and high-risk gynecology exams differently than in the past," BCBS of Michigan (BCBSM) recently announced. To align the company's guidelines with Medicare's, BCBSM will also accept G0101 for a pelvic and breast exam. Plus, if the physician performs a separate, significantly identifiable E/M, you may also report the appropriate code appended with modifier -25.

BCBSM's announcement also clarifies that the payer will cover a Pap smear in addition to a gynecological or pelvic and breast exam. "Q0091 is payable both alone and with exam codes S0610, S0612 or G0101," according to BCBSM's January 2003 Physician Update.

Finally, other commercial insurers may play by a different set of rules. First the simple part: Many private payers recognize and cover the preventive medicine service, which you should bill using 99381-99397. You will need to append modifier -25 if you report the pelvic and breast exam separately.

Coding the gynecological exam is not as easy. Most health plans deny HCPCS codes, but some plans reimburse them. If the insurer doesn't cover the codes, you may have to bill the patient for the clinical breast and pelvic exam or include the fee in the preventive exam. So check with the insurance company for its guidelines.

With some third-party payers, you have two options for reporting the Pap smear: Q0091 or 99000 (Handling and/or conveyance of specimen for transfer from the physician's office to a laboratory). "A fair number of commercial payers reimburse the national code," says Jaime Darling, CPC, certified coder for Graybill Medical Group in Escondido, Calif. If the insurer denies Q0091, she recommends trying 99000.

If these methods have proved fruitless, you should review the diagnoses that you're using for each element. "In the case of Medicare, diagnosis is crucial because of limitations on coverage, some of which are diagnosis-specific," Moore says.

For the gynecological exam, you should report the diagnosis that represents the patient's condition and the test performed. For a non-risk patient who has a pelvic and breast exam (G0101), you should report diagnosis code V76.2 (Special screening for malignant neoplasms of cervix) or V76.49 ( other sites). When the FP performs a gynecological exam (S0610-S0612) on a normal-risk patient, use diagnosis code V72.3 (Special investigations and examinations; gynecological examination). On the other hand, if the FP defines the patient as high-risk, you should assign V15.89 (Other specified personal history presenting hazards to health; other) for G0101.

For the Pap smear, the same risk differences apply. For instance, if the patient meets high-risk criteria, you should report the same high-risk diagnosis code (V15.89) as you did for the gynecological exam. If the patient is at normal risk, link Q0091 to V76.2 (Special screening for malignant neoplasms of the cervix).

And for the preventive exam, use V70.0 (General medical examination; routine general medical examination at a health care facility).