Wiki Well woman exam billed to Medicare but no pelvic exam/pap

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cgarciamck87@gmail.com

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A patient came in for her well woman exam but did not do a pelvic exam or pap smear. Had she had the pelvic i know we would bill the G0101. But what would it be in this case? Would this be an E/M?
 
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9938x or 9939x. Preventive visits (basically the well exam). E&Ms are only for visits with chief complaints/problems/illnesses/injuries.
G0101 and Q0091 are Medicare HCPCS codes for Pap/Breast/Pelvic. Some commercial payers will cover them.
 
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Pam Warren said:
9938x or 9939x. Preventive visits (basically the well exam). E&Ms are only for visits with chief complaints/problems/illnesses/injuries.
G0101 and Q0091 are Medicare HCPCS codes for Pap/Breast/Pelvic. Some commercial payers will cover them.
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So this particular patient has a medicare advantage plan. 99397 was billed to them but it was denied. "Statutorily excluded service". Would this mean then patient is financially responsible?
 
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cgarciamck87@gmail.com said:
So this particular patient has a medicare advantage plan. 99397 was billed to them but it was denied. "Statutorily excluded service". Would this mean then patient is financially responsible?
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Yes, the patient would be responsible for services excluded from her coverage. You may consider waiving this from a customer service perspective if your practice didn't let her know in advance. Not required, but something to consider. And use it as a learning experience moving forward to not perform services you know will not be covered without informing patient in advance and collecting payment.
 
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99397 is statutorily excluded from Medicare Coverage, per federal guidelines. As such, no ABN is required and you may balance bill the patient, which should be evident on your remittance advice. A good rule of thumb is to never provide these for Medicare recipients; instead consider Annual Wellness Visits, addressing chronic conditions and billing an E&M with a comprehensive exam, or billing only pap/breast/pelvic. Medicare has an excellent preventive service guide that may be helpful for you. https://www.medicare.gov/coverage/preventive-screening-services

If you have a large Medicare population, you will need to wrap your head around Medicare guidance, otherwise you stand to lose revenue (and anger your patients).
 
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Pam Warren said:
99397 is statutorily excluded from Medicare Coverage, per federal guidelines. As such, no ABN is required and you may balance bill the patient, which should be evident on your remittance advice. A good rule of thumb is to never provide these for Medicare recipients; instead consider Annual Wellness Visits, addressing chronic conditions and billing an E&M with a comprehensive exam, or billing only pap/breast/pelvic. Medicare has an excellent preventive service guide that may be helpful for you. https://www.medicare.gov/coverage/preventive-screening-services

If you have a large Medicare population, you will need to wrap your head around Medicare guidance, otherwise you stand to lose revenue (and anger your patients).
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hey there,

I've been discussing all this with someone else and waiting to get to hear back from them, but just wanted to get your opinion, and perhaps a couple questions answered. So when there is no pelvic exam and it's medicare for an annual wellness visit charge the 99397 etc etc from that series of codes depending on new/established etc. if there is a pelvic exam charge the g0101? and medicare says they cover 1 wellness visit a year but is that only for medicare part b people i think i read? so where i am they cover the g0101 every 2 years and if we have them come back the following year it would be a 99397 but only if its just a wellness exam. if they did a pelvic exam then charge the g0101 again and if they signed an abn we can put the charge to the patient? same with if it was 99397 and they signed abn and medicare doesn't pay and put the charge to patient?

I've only been coding a couple years and code for an obgyn and my training wasn't the best i feel. she rushed through and didn't explain why they did what they did or how to find any info even tho i do try to do as much reading and looking up and consulting with others as i can. We also never charge for paps.....we charge for wet mounts sometimes for non medicare patients but i think we don't charge for paps because the affordable care act includes it in preventative care, so is that included in the 99397 or we still charge for the pap like we do for the 99397 and it's covered by insurance? We take and look at the wet mounts 87210 under microscope at our practice but the old coder also never charged a medicare patients for a q0091 ever from what i noticed and not sure why or if that has something to do with quest coming to our office everyday to gather whatever it is they're gathering.....

thanks so much!
 
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I've been discussing all this with someone else and waiting to get to hear back from them, but just wanted to get your opinion, and perhaps a couple questions answered. So when there is no pelvic exam and it's medicare for an annual wellness visit charge the 99397 etc etc from that series of codes depending on new/established etc. No, those are not the codes for Annual Wellness Visits. Those are the codes for Routine Preventive Care and not covered by Medicare. Make sure you know what your patient is expecting when they come in for a visit, otherwise you'll be writing off charges. if there is a pelvic exam charge the g0101? This code is for Breast and Pelvic, and you have to meet the documentation criteria set by Medicare to bill that....they expect that several areas be examined. and medicare says they cover 1 wellness visit a year but is that only for medicare part b people i think i read? See my comment above; Medicare is talking about the Annual Wellness Visit (new/subsequent)---you need to get yourself to the CMS website and read about these various covered services so that you don't cost your practice money by coding the wrong service. so where i am they cover the g0101 every 2 years and if we have them come back the following year it would be a 99397 but only if its just a wellness exam. if they did a pelvic exam then charge the g0101 again and if they signed an abn we can put the charge to the patient? same with if it was 99397 and they signed abn and medicare doesn't pay and put the charge to patient? Again....99397 is not the AWV; you'll have to do your research.

I've only been coding a couple years and code for an obgyn and my training wasn't the best i feel. she rushed through and didn't explain why they did what they did or how to find any info even tho i do try to do as much reading and looking up and consulting with others as i can. We also never charge for paps.....we charge for wet mounts sometimes for non medicare patients but i think we don't charge for paps because the affordable care act includes it in preventative care, so is that included in the 99397 or we still charge for the pap like we do for the 99397 and it's covered by insurance? We take and look at the wet mounts 87210 under microscope at our practice but the old coder also never charged a medicare patients for a q0091 This is the code for obtaining a pap smear; and there are limitations as to how often this can be done. ever from what i noticed and not sure why or if that has something to do with quest coming to our office everyday to gather whatever it is they're gathering..... What you're describing has nothing to do with OBGYN coding training. You're dealing with Medicare---they have their own set of rules and regulations, and you'll need to learn about those through both CMS and your MAC (Medicare Administrative Contractor). Depending on where your practice is located, you have a MAC That also outlines guidance.

thanks so much!

MLN006559 – Medicare Preventive Services

Preventive Services Chart. Learn about codes; who is covered; frequency; and what the Medicare patient pays.
www.cms.gov
 
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Pam Warren said:
3I've been discussing all this with someone else and waiting to get to hear back from them, but just wanted to get your opinion, and perhaps a couple questions answered. So when there is no pelvic exam and it's medicare for an annual wellness visit charge the 99397 etc etc from that series of codes depending on new/established etc. No, those are not the codes for Annual Wellness Visits. Those are the codes for Routine Preventive Care and not covered by Medicare. Make sure you know what your patient is expecting when they come in for a visit, otherwise you'll be writing off charges. if there is a pelvic exam charge the g0101? This code is for Breast and Pelvic, and you have to meet the documentation criteria set by Medicare to bill that....they expect that several areas be examined. and medicare says they cover 1 wellness visit a year but is that only for medicare part b people i think i read? See my comment above; Medicare is talking about the Annual Wellness Visit (new/subsequent)---you need to get yourself to the CMS website and read about these various covered services so that you don't cost your practice money by coding the wrong service. so where i am they cover the g0101 every 2 years and if we have them come back the following year it would be a 99397 but only if its just a wellness exam. if they did a pelvic exam then charge the g0101 again and if they signed an abn we can put the charge to the patient? same with if it was 99397 and they signed abn and medicare doesn't pay and put the charge to patient? Again....99397 is not the AWV; you'll have to do your research.

I've only been coding a couple years and code for an obgyn and my training wasn't the best i feel. she rushed through and didn't explain why they did what they did or how to find any info even tho i do try to do as much reading and looking up and consulting with others as i can. We also never charge for paps.....we charge for wet mounts sometimes for non medicare patients but i think we don't charge for paps because the affordable care act includes it in preventative care, so is that included in the 99397 or we still charge for the pap like we do for the 99397 and it's covered by insurance? We take and look at the wet mounts 87210 under microscope at our practice but the old coder also never charged a medicare patients for a q0091 This is the code for obtaining a pap smear; and there are limitations as to how often this can be done. ever from what i noticed and not sure why or if that has something to do with quest coming to our office everyday to gather whatever it is they're gathering..... What you're describing has nothing to do with OBGYN coding training. You're dealing with Medicare---they have their own set of rules and regulations, and you'll need to learn about those through both CMS and your MAC (Medicare Administrative Contractor). Depending on where your practice is located, you have a MAC That also outlines guidance.

thanks so much!

MLN006559 – Medicare Preventive Services

Preventive Services Chart. Learn about codes; who is covered; frequency; and what the Medicare patient pays.
www.cms.gov
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Thank you!

I saw G0438 and G0439 were for annual wellness visits is that considered to be within the same verbiage of a "well woman exam".....and according to this guide below and i think what you were saying though that if it's a covered year for someones G0101 and they are straight medicare and a pelvic exam wasn't done for whatever reason mabye they couldn't tolerate it......then you charge the 99397 etc to the patients responsibility?


i don't see how thats fair to make the patient pay just because less work was done and if they were able to tolerate the pelvic exam and they were within their covered year for g0101 then it would have been covered.... I know you can't charge the g0101 without the pelvic exam and all components etc

so just confirming when no pelvic exam was done when they are coming in for the their g0101 then charge the 99397 if they are established to the patient?

thanks!
 
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There is no reason why during an IPPE or AWV that the provider can't also do the breast, pelvic, pap. They just have to meet the documentation guidelines. That way, it's all covered, and the patient has had their preventive care addressed.
Usually, by the time patients are covered by Medicare, there's no need for the 99397; they have chronic conditions addressed with an E&M visit, and the other preventive care is medically necessary. Educate your providers on doing the appropriate amount of work so that these services are billable. If they're not going to do the work, they can't expect to get paid. :giggle:
 
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Pam Warren said:
There is no reason why during an IPPE or AWV that the provider can't also do the breast, pelvic, pap. They just have to meet the documentation guidelines. That way, it's all covered, and the patient has had their preventive care addressed.
Usually, by the time patients are covered by Medicare, there's no need for the 99397; they have chronic conditions addressed with an E&M visit, and the other preventive care is medically necessary. Educate your providers on doing the appropriate amount of work so that these services are billable. If they're not going to do the work, they can't expect to get paid. :giggle:
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thanks! it's just sometimes the older patients can't tolerate the pelvic exam because they are to stenoic or to painful or they just opt not to have it....... so then i get stuck with a g0101 without a pelvic exam :)
 
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Korbc said:
thanks! it's just sometimes the older patients can't tolerate the pelvic exam because they are to stenoic or to painful or they just opt not to have it....... so then i get stuck with a g0101 without a pelvic exam :)
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If the patient is coming in to address a problem, then E&M 99211-99205 would be appropriate. Discussing menopause symptoms? Vaginal or vulvar atrophy? Painful intercourse? All those could be billed with problem oriented E&M. If the patient is going to the gyn annually, but not having an exam, and doesn't have any complaints or problems, I don't fully understand why.
 
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They are there for their breast exam and for cervical/vaginal cancer screening. That's the type of visit they are booked for the g0101, covered every 2 years if low risk and every year if high risk. But sometimes they decide they don't want the pelvic exam or the pelvic exam is attempted but it's to painful and they stop etc etc. So if anything else is mentioned at all like the conditions you mention I guess I'll just bill a problem e/m......
 
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