Primary Care Coding Alert

Question: For codes G0402, G0438, & G0439 when a female patient comes in for any one of these codes, can they have a pap smear with this visit? If yes, does it require modifiers? Also, if the patient is reviewed for any other problem, can an E/M code be reported along with the wellness visit codes? What all does Medicare pay for when patient comes in for these codes?

Tennessee Subscriber

Answer: When reporting an initial preventive physical examination code G0402 (Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment) or an annual wellness visit code, G0438 (Annual wellness visit; includes a personalized prevention plan of service (PPS), initial visit) or G0439 (…subsequent visit), certain services like a prostate examination, cervical cancer screening or a Pap smear is not part of these preventive service codes.

So, if your practitioner performs a test that is not under the scope of covered services listed in the preventive service codes, you will have to report these services separately using an appropriate code. In this case scenario, you have mentioned the Pap smear. For Medicare patients, when your FP performs a Pap smear, you will have to report it with Q0091 (Screening papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory).

In case, your clinician is addressing other issues along with the annual wellness visit (AWV), you can report an appropriate E/M service code for the visit. However, it is important to note that CMS noted in the Federal Register that they do not expect to see many problem services billed on the same date of service as the AWV because of the time involved with performing the AWV. So be sure the E/M problem you’re reporting in addition to the AWV is significant, not minor.

As Correct Coding Initiative (CCI) edits bundle E/M codes into the AWV codes with the modifier indicator ‘1,’ you’ll have to append the modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M code to be able to separately report both the codes for the same session.

Note: These above mentioned HCPCS codes are for Medicare patients. When reporting for other commercial carriers, ensure that they accept these codes or prefer other CPT^® codes (99381-99397) to report the annual wellness visit.