Quick Tips:
How to Keep Well-Woman Exam Claims Squeaky-Clean
Published on Fri Aug 25, 2006
Say goodbye to your confusion over screening guidelines
To code a well-woman exam correctly, you-ve got to know two key concepts: how Medicare and private-payer guidelines differ, and when you should separately code breast/pelvic exams and Pap smears.
Best bet: Use these two quick tips for accurate well-woman coding. 1. Break Out Services for Medicare If the family physician provides a complete well-woman exam for a Medicare patient, you should report G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) for the breast and pelvic exams. When the physician also obtains a Pap smear, use Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory), says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania.
If these are done as part of an annual preventive medicine visit, the physician should also code the appropriate preventive medicine service code (e.g., 99397, Periodic comprehensive preventive medicine reevaluation and management of an individual ...; 65 years and over).
If these are done in conjunction with a problem-oriented visit, you can report a new or established patient E/M code (99201-99215) in addition to G0101 and Q0091, Pohlig says.
But the FP must have documented a separate and distinct E/M service, and you must attach modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the E/M code. For example, the physician performs the well-woman exam but also evaluates and manages the patient's ongoing dysfunctional uterine bleeding.
Important: For Medicare patients at normal risk, you can report a Pap smear only once every two years. The diagnoses your physician will use in these cases include V72.31 (Routine gynecological examination), V76.2 (Special screening for malignant neoplasms; cervix) and V76.47 (... other sites; vagina), says Pat Larabee, CPC, CCP, a coding specialist at InterMed, a multispecialty healthcare network in South Portland, Maine. High-Risk Coding If the patient is high-risk, you can bill the Pap smears annually. To classify a patient as high-risk, you will likely use V15.89 (Other specified personal history presenting hazards to health; other) for medical justification of a screening Pap smear, Larabee says.
-Medicare has specific requirements that have to be met for a patient to be considered high-risk,- Larabee adds. For this reason, your physician should supply secondary diagnoses to explain why the patient is high-risk. These diagnoses include:
- History of HIV (V08 or 042)
- History of sexually transmitted diseases (V13.8)
- Five or more sexual partners (V69.2)
- Began sexual activity before 16 years of age (V69.2)
- Diethylstilbestrol (DES) exposure (760.76)
- Seven years without a Pap smear (V15.89)
- Absence of three consecutive negative Pap results (795.0x). 2. Rely on CPT Codes for Private Insurers [...]
