Primary Care Coding Alert

Question: In the February issue of Family Practice Coding Alert, you said it was not acceptable to bill Pap smears with an office visit (99211-99215 office or other outpatient visit for the evaluation and management of an established patient) since there is no separate code just for a Pap smear. Medicare, however, has told us to use the E/M code only when the patient comes in for a Pap smear and is seen for another E/M service. In addition, Medicare asks us to append a modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code. Can you clarify? If there are no other complaints, how do you charge a Medicare patient for the Pap smear (V72.6, special investigations and examinations; laboratory examination)?

Kansas Subscriber

Answer: Our article did state that, in general, you could not bill for a collection of a Pap smear because there is no separate code for that service. It goes on to explain that special circumstances exist for Medicare patients.

To summarize, first determine whether the patient is Medicare or a commercial insurance patient. If the patient were covered by commercial insurance, you would bill only a problem-oriented E/M service (99201-99215) or preventive service (99381-99397) depending on the reason for the visit. If a Pap smear is taken, the actual smear is billed by the office or lab, depending on your specific arrangements, using codes from the pathology section (88141-88167). There is no separate code for collection of the Pap smear.

If the patient is covered by Medicare, you must differentiate between preventive services and problem-oriented services. If the patient is receiving preventive services, you are allowed to bill to Medicare the portion (G0101, breast and pelvic exam; and Q0091, Pap smear collection) that is a covered service, separately from the overall preventive service.

If the patient is being seen for a problem oriented E/M for a non-gynecological problem (such as a cold) and requests a preventive breast, pelvic and Pap at the same visit, then you may bill G0101 and Q0091 along with the E/M service. In both of these scenarios, the actual Pap smear is billed through the independent laboratory.
If the patient presents with a gynecological complaint that prompts the need for a Pap smear, then the service would be coded only as a regular E/M service, and you would not code G0101 or Q0091. Again, the actual Pap smear would be billed by the laboratory.

Codes G0101 and Q0091 do not represent additional billable services. They actually were designed to allow Medicare to pay for just a portion of a larger service.

Editors note: The previous question was answered by Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C.