Wiki well woman G0101

[klapetri@ilovemygyn.com]

OBGYN -NY

We have been receiving denials from Emblem Health for cpt codes 99384-99397 stating G0101 must be billed.
Per my provider rep. Emblem Health August 2021 "In the know" Medicare patients for an annual exam G0101 must be used, for dates of service on or after 1/1/2020.
Instead of using 99384-99397
Claims are denying for all emblem health policy, doesn't matter if Medicare or commercial poilcy...

Is anyone else having the same issue?

 

[Karajag]

G0101 is used for Medicare patients, and can only be billed every two years (and they are very strict on the dates). If the patient has a pap performed at that time then you can also bill a Q0091 with it. If patient has a non-Medicare plan then the 99395-99397 (established patient) can be billed yearly. I bill with dx code Z01.419 or Z04.111 if there are abnormal findings. CPT G0101 can ONLY be billed yearly if the patient is considered high-risk.

 

[klapetri@ilovemygyn.com]

Thanks for the reply. Yes I'm aware G0101 is for Medicare members every two years unless high risk.
My question is has anyone heard of commercial payers i.e. Emblem Health requiring ob/gyn to bill G0101 instead of 99384-99397?
Per my provider rep. Emblem Health August 2021 "In the know" Medicare patients for an annual exam G0101 must be used, for dates of service on or after 1/1/2020.
Instead of using 99384-99397

 

[Karajag]

Well that will teach me to read a little closer I guess. I know there are a number of commercial payers that are no longer accepting those codes for their Medicare patients and are requiring the G0101 be billed instead.

 

[samyjm13]

To add to this, it is my understanding that at least 7 of 11 elements of the breast/pelvic exam is required before you can submit G0101

 

[nielynco]

OBGYN -NY

We have been receiving denials from Emblem Health for cpt codes 99384-99397 stating G0101 must be billed.
Per my provider rep. Emblem Health August 2021 "In the know" Medicare patients for an annual exam G0101 must be used, for dates of service on or after 1/1/2020.
Instead of using 99384-99397
Claims are denying for all emblem health policy, doesn't matter if Medicare or commercial poilcy...

Is anyone else having the same issue?

It is my understanding that many Medicare Advantage Plans are changing to Medicare rules and in that case G0101 would be required for the annual gyn exam under their rules. I am not seeing any commercial payers doing that yet (that is coverage for patient swho are not Medicare), but some Medicaid programs have also switched to G0101 instead of the preventive medicine codes. As you probably already know, those codes (99384-99397) have never been a covered benefit under standard fee-for-service Medicare and it was the reason they developed the G0101/Q0091 codes to begin with way back in 1998 (yes it has been that long ago!). But when the Medicare Advantage programs were developed the payers were allowed to select the codes to bill, so long as the patients were getting the same benefits as regular Medicare.