Primary Care Coding Alert

Question: Our provider recently performed incomplete G0101 and Q0091 services to a patient. What is the correct way to bill this to a commercial payer?

Codify Subscriber

Answer: You could report this scenario in two different ways.

The first would be to use 99384-99387/99394-99397 (Initial/Periodic comprehensive preventive medicine evaluation and management of an individual …), which you would normally use to bill a private payer for the services described by G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) and Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory).

Codes G0101 and Q0091 represent services that would typically be part of the age and gender appropriate physical exam normally included in a preventive medicine visit described by codes 99384-99387/99394-99397. Because Medicare does not cover the preventive medicine visits described by those CPT^® codes but does cover the two screening services in question, the Centers for Medicare and Medicaid Services (CMS) created codes G0101 and Q0091 to facilitate reporting of those particular Medicare benefits.

Since you’re billing a commercial carrier rather than Medicare, you only need to rely on the CPT^® codes. As your provider did not provide full services for either, you could attach modifier 52 (Reduced services) to the age-appropriate preventive medicine code to let your payer know you are reporting a reduced charge.

If the service(s) was sufficiently incomplete that you don’t feel it appropriate to report a preventive medicine visit, another possibility may be to code for counseling based on the amount of time your provider spent with the patient, assuming there was some counseling involved. Since G0101 and Q0091 both represent “screening,” the implication is that any counseling services provided were likely preventive in nature. Accordingly, if using a counseling code, you could use a code from 99401-99404 (Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure) …).

Don’t forget the Dx: If your provider does indicate that counseling was the major focus of the patient’s visit, look to the appropriate ICD-10 diagnosis code that reflects the nature of the counseling. This might include a code from the Z30.0- (Encounter for general counseling and advice on contraception), Z31.6- (Encounter for general counseling and advice on procreation), Z70.- (Counseling related to sexual attitude, behavior, and orientation), or Z71.89 (Other specified counseling) codes to justify the service.