Primary Care Coding Alert

Nugget: Family practices will get the reimbursement to which they are ethically entitled by correctly assigning G0101 and Q0091 for gynecological screening exams in Medicare patients.

Many family practices do not receive the payment they deserve for screening Pap smears or breast and pelvic exams because coders fail to assign proper codes for Medicare patients. These individuals include not only elderly women, but also younger patients eligible to receive Medicare benefits those who may be physically or mentally disabled, for instance, or those who suffer from permanent kidney failure.

After the Balanced Budget Act of 1997, Medicare began to cover increased preventive services and added two codes for gynecological screening exams 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).

Medicare provides coverage for these services routinely once every three years. The screening exams may be covered more often if the patient is of childbearing age. In addition, more frequent screenings and Pap smears are allowed for women of any age who are deemed to be at greater risk for cancer.

These codes are particularly applicable to family practitioners, as well as internists and ob/gyns, points out Jan Rasmussen, CPC, coding consultant and instructor for Med Learn, a medical practice management training and consulting firm based in Minneapolis/St. Paul, Minn. However, when I perform chart reviews, I often see that they are not billing for these services for their Medicare patients. Or, if they are, they are not including the proper documentation.

This failure to report or improper reporting results in a significant amount of lost revenue for family practices, she adds.

When and How to Assign G0101

Clinical breast and pelvic screening examinations are covered by Medicare Part B when ordered by a physician, as long as they meet specific requirements, according to HCPCS 2000. The requirements include:

the patient has not had a test during the preceding three years;

the patient is a woman of childbearing age; or

there is evidence, on the basis of medical history or other findings, that she is at high risk of developing cervical cancer and her physician (or other authorized practitioner) recommends that she have the test performed more frequently than every three years.

High-risk factors for cervical and vaginal cancer are defined as early onset of sexual activity (younger than age 16), multiple sexual partners (five or more in a lifetime),
history of sexually transmitted disease (including HIV infection), fewer than three negative or no Pap smears within the previous seven years, and DES-exposed (diethylstilbestrol) daughters of women who took DES during pregnancy.

For the screening breast or pelvic exam services to be covered by Medicare, the physicians exam must include at least seven of 11 clearly defined components. One of the most common problems Rasmussen sees in chart reviews is that many family physicians who report G0101 do not document all of the elements they examine. Sometimes, they will report five or six of the necessary elements, but not the seven that are required to support the code, she says.

The 11 elements are:
1. inspection and palpation of breasts for masses or lumps, tenderness, symmetry or nipple discharge;

2. digital rectal examination, including sphincter tone, presence of hemorrhoids and rectal masses;

3. Pelvic examination (with or without specimen collection for smears and cultures), including external genitalia (general appearance, hair distribution or lesions)

4. urethral meatus (size, location, lesions or prolapse)

5. urethra (masses, tenderness or scarring)

6. bladder (fullness, masses or tenderness)

7. vagina (general appearance, estrogen deficit, discharge, lesions, pelvic support, cystocele or retocele)

8. cervix (general appearance, lesions or discharge)

9. uterus (size, contour, position, mobility, tenderness, consistency, descent or support)

10. adnexa/parametria (masses, tenderness, organomegaly or nodularity)

11. anus or perineum.

Editors Note: This description was published in HCPCS 1999 and taken from the Documentation Guidelines for Evaluation and Management Services, published in May 1999 by the Health Care Financing Administration (HCFA) and the American Medical Association (AMA).

Coding guidelines indicate that G0101 may be assigned in addition to an evaluation and management (E/M) code when a separately identifiable E/M service is provided. For instance, a physician may examine a patient recently admitted to a nursing facility. During the course of the exam, the patient mentions she has not had a pelvic examination in five years. Under these conditions, the physician may report the appropriate E/M code 99301-99303 (evaluation and management of a new or established patient involving a nursing facility assessment at the time of initial admission or readmission to the facility), depending on the level of service, as well as G0101.

When and How to Assign Q0091

HCFA has assigned a Q code to Pap smear collection to identify the code as temporary. A permanent code will be assigned in the near future, the agency reports, at which point the Q code will be deleted and cross-referenced to the new code.

Because of their temporary status, some Q codes fall under the jurisdiction of the local Medicare carrier. In the case of Q0091, however, most physicians report consistent payment. Most of our practices are using the Q0091 for Medicare Pap collection and we are getting paid as expected without difficulty, says Jean Stoner, CPC, manager of coder training for the University of Pittsburgh Medical Center (UPMC) Health System in Pittsburgh, Pa.

As with G0101, Medicare covers screening Pap smears only once every three years unless the family physician suspects and documents an abnormality that requires the test more frequently. Abnormalities that may justify that interval to be shortened include conditions such as cervical dysplasia (622.1).

In view of the triennial requirements of Q0091, Stoner says most of the family practices within the UPMC system ask patients to sign an advance beneficiary notice (ABN) whenever they come in for the exam. This waiver states that the procedure may not be covered by Medicare. Then, if Medicare does not pay for the Pap smear in one of the non-covered years, the practice may bill the patient and not incur revenue loss.

Medicare also requires that any report of a Pap smear code with a pelvic examination claim must be reported with one of two specific diagnosis codes to clearly indicate if the patient is at high or low risk for cancer:

V76.2 (special screening for malignant neoplasms of the cervix, indicates low risk)

V15.89 (other specified personal history presenting hazards to health, indicate high risk)

Hazards that indicate high risk may include conditions such as previous history of abnormal Pap smear or DES exposure.