I use them for the payors that allow them. Why? Because sometimes the patient will come in for a comprehensive PE by their male doctor and 3 months later, come back to see the NP for just her GYN exam & Pap.
Here's the guidelines I use (I'm in MA) (sorry about the formatting, didn't copy well here):
Coding & Billing for Medicare GYN Exams
• Use HCPCS codes G0101 (screening pelvic & breast exam) AND Q0091 (obtain cervical or vaginal smear) with one of the
diagnosis codes below:
• If patient is HIGH-RISK, use
diagnosis code V15.89
• If patient is LOW-RISK, use
diagnosis code V72.31
PART TWO – All other payors
Use V72.31 as the diagnosis. See payor-specific guidelines below for procedure coding requirements.
AETNA
• S0610 for NEW patients
• S0612 for ESTABLISHED patients
• If complete PE is also done (V70.0), bill only the age-appropriate preventive exam
BCBS – EXCEPT FOR BLUE CARE 65 AKA MEDICARE ADVANTAGE HMO
• S0610 for NEW patients
• S0612 for ESTABLISHED patients
• Exception – NPs can NOT bill these codes if they are billing direct (under their own names, doc not in office). If supervising doc not in office and NP billing direct, then use the G and Q codes instead.
*** IF COMPLETE PE (V70.0) ALSO DONE, BILL THE AGE-APPROPRIATE LINKED TO V70.0 AND THE G0101 LINKED TO DX v72.31 *** instead of the S-code. (The S codes bundle into any other E&M done on the same day.) This applies also if a separate problem is addressed – If a problem visit also done (e.g. 99213), bill that with -25 modifier linked to problem dx and then the G0101 linked to V72.31
BLUE CARE 65 / MEDICARE ADVANTAGE HMO
• G0101 and Q0091
• If regular complete PE (V70.0) also indicated, bill the age appropriate exam linked to V70.0 plus the G0101 and Q0091 linked to V72.31 (Q code may deny as bundled)
BMC HealthNet
• Use age-appropriate preventive exam (e.g. 99395)
Cigna
• S0610 for NEW patients
• S0612 for ESTABLISHED patients
• If complete PE is also done (V70.0), bill only the age-appropriate preventive exam
Connecticare
• Use age-appropriate preventive exam (e.g. 99395)
Consolidated
• G0101 and Q0091
• If regular complete PE (V70.0) also indicated, bill the age appropriate exam linked to V70.0 plus the G0101 and Q0091 linked to V72.31 (Q code may deny as bundled)
Coventry
• G0101 and Q0091
• If regular complete PE (V70.0) also indicated, bill the age appropriate exam linked to V70.0 plus the G0101 and Q0091 linked to V72.31 (Q code may deny as bundled)
Fallon
• G0101 and Q0091
• If regular complete PE (V70.0) also indicated, bill the age appropriate exam linked to V70.0 plus the G0101 and Q0091 linked to V72.31
• If a PROBLEM visit 99214, 99215, 99203, 99204, or 99205 is also indicated, bill ONLY the problem visit.
• If a Problem visit 99212, 99213, 99201, or 99202 is also indicated, bill only the G and Q codes.
GIC/UNICARE
• G0101 and Q0091
• If regular complete PE (V70.0) also indicated, bill only the age appropriate exam (the G & Codes bundle).
• They will pay for a separate problem visit w/ mod -25
Great West
• S0610 for NEW patients
• S0612 for ESTABLISHED patients
*** IF COMPLETE PE (V70.0) ALSO DONE, BILL THE AGE-APPROPRIATE LINKED TO V70.0 AND THE G0101 LINKED TO DX v72.31 *** instead of the S-code. (The S codes bundle into any other E&M done on the same day.) This applies also if a separate problem is addressed – If a problem visit also done (e.g. 99213), bill that with -25 modifier linked to problem dx and then the G0101 linked to V72.31
Harvard Pilgrim
• G0101 and Q0091
• If regular complete PE (V70.0) also indicated, bill the age appropriate exam ONLY (G & Q bundle w/ any other E&M service)
• If problem visit also indicated, bill ONLY The G & Q codes.
Health New England
• Use age-appropriate preventive exam (e.g. 99395)
MassHealth
• Use age-appropriate preventive exam (e.g. 99395)
Network Health
• G0101 only (Q0091 bundles)
• If complete PE is also done (V70.0), bill only the age-appropriate preventive exam
Tricare
• G0101 only (Q0091 denies as bundled)
• If complete PE or problem visit also indicated, bill only E&M as Tricare bundles the G and Q codes into any other E&M on same day
Tufts (NON_MEDICARE TUFTS ONLY)
• S0610 for NEW patients
• S0612 for ESTABLISHED patients
*** IF COMPLETE PE (V70.0) ALSO DONE, BILL THE AGE-APPROPRIATE LINKED TO V70.0 AND THE Q0091 plus G0101-59 LINKED TO DX v72.31 *** instead of the S-code. (The S codes bundle into any other E&M done on the same day.) This applies also if a separate problem is addressed – If a problem visit also done (e.g. 99213), bill that with -25 modifier linked to problem dx and then the G0101 linked to V72.31
Tufts Medicare Preferred:
• G0101 ONLY (Q0091 is bundled per their policy)
*** IF COMPLETE PE (V70.0) ALSO DONE, BILL THE AGE-APPROPRIATE LINKED TO V70.0 AND THE Q0091 plus G0101-59 LINKED TO DX v72.31 This applies also if a separate problem is addressed – If a problem visit also done (e.g. 99213), bill that with -25 modifier linked to problem dx and then the G0101 linked to V72.31
United Healthcare
• G0101 and Q0091
• If complete PE (v70.0) also done, bill only the age-appropriate code; UHC bundles the G&Q codes in to the 993xx codes.