Wiki PCP referred to OBGYN for abnormal pap - help!

[Sdrivera]

A patient was referred by PCP to OBGYN for evaluation for abnormal pap smear. The Dx code on the referral is R87.619. The abnormal pap was from about 1 year ago, per the PCP note. The OBGYN coded G0101, Q0091, and 99000 with R87.619 for all CPT codes. The clearinghouse rejected the claim due to NCD policy 210.2 - Screening Pap Smears and Pelvic Examinations for Early Detection of Cervical or Vaginal Cancer. I'm not sure how to correct this to be able to educate the provider as well on the coding. My provider uses G0101 and Q0091 almost every time a patient comes in for an annual or WWE, but I feel like he's not using these codes correctly and losing money.
Thank you for any assistance!

 

[nielynco]

A patient was referred by PCP to OBGYN for evaluation for abnormal pap smear. The Dx code on the referral is R87.619. The abnormal pap was from about 1 year ago, per the PCP note. The OBGYN coded G0101, Q0091, and 99000 with R87.619 for all CPT codes. The clearinghouse rejected the claim due to NCD policy 210.2 - Screening Pap Smears and Pelvic Examinations for Early Detection of Cervical or Vaginal Cancer. I'm not sure how to correct this to be able to educate the provider as well on the coding. My provider uses G0101 and Q0091 almost every time a patient comes in for an annual or WWE, but I feel like he's not using these codes correctly and losing money.
Thank you for any assistance!

This Pap smear was being performed for a diagnostic reason, not a screening. Therefore, Medicare will deny the G and Q codes because the service was not screening. They will apply their diagnostic Pap rules and the collection and exam becomes part of the E/M service which is what you should have billed them with this diagnosis. You will also not be paid separately for 99000 and you should not be billing this code if you are also appropriately billing Q0091 (which includes the collection). Medicare puts an indicator "B" on code 99000 which means they will almost always bundle it with other services.

 

[Sdrivera]

This Pap smear was being performed for a diagnostic reason, not a screening. Therefore, Medicare will deny the G and Q codes because the service was not screening. They will apply their diagnostic Pap rules and the collection and exam becomes part of the E/M service which is what you should have billed them with this diagnosis. You will also not be paid separately for 99000 and you should not be billing this code if you are also appropriately billing Q0091 (which includes the collection). Medicare puts an indicator "B" on code 99000 which means they will almost always bundle it with other services.

Thank you!

 

[fia.williams]

If patient comes in for WWE (breast, pap of cervical stump, pelvic) and insurance is BCBS, wouldn't the codes be 99391-395 for an established visit? I'm new to OB/GYN coding but I have a claim where someone else previously coded this scenario with a G0438 which I thought was only usable for Medicare only claims 12 months after the patient was enrolled in Medicare. Is G0438 used by any other payer besides Medicare advantage?

 

[csperoni]

If patient comes in for WWE (breast, pap of cervical stump, pelvic) and insurance is BCBS, wouldn't the codes be 99391-395 for an established visit? I'm new to OB/GYN coding but I have a claim where someone else previously coded this scenario with a G0438 which I thought was only usable for Medicare only claims 12 months after the patient was enrolled in Medicare. Is G0438 used by any other payer besides Medicare advantage?

I have never seen an obgyn use G0438. You are correct that code is for an initial annual wellness visit, but must be > 12 months after Medicare enrollment (you might be confusing with the "Welcome to Medicare" code). Regardless, it is not for a well woman exam. While it is a Medicare recognized code, whether or not other carriers recognize this is up to the carrier.
If the patient has BCBS, the most likely correct coding is preventive 9938X-9939X. Some Medicare Advantage plans may require (as Medicare does) G0101 and Q0091.