Wiki Yearly preventative exam/gynecology

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broundy

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Help! One of my providers does a very large amount of yearly preventative exams. She does the entire exam not just the gyn portion, but I am getting quite a few denials saying they must be done by pcp. My problem now is my manager wants me to code the preventative CPT code and use just the V72.31 for just the gyn side. Now what happens if the patient goes to their pcp for their yearly general exam and they too charge the CPT yearly preventative exam code? I cannot believe the insurances will pay twice on a charge that is a once a year deal. What do I do?

Thank you !:eek:
 
broundy said:
Help! One of my providers does a very large amount of yearly preventative exams. She does the entire exam not just the gyn portion, but I am getting quite a few denials saying they must be done by pcp. My problem now is my manager wants me to code the preventative CPT code and use just the V72.31 for just the gyn side. Now what happens if the patient goes to their pcp for their yearly general exam and they too charge the CPT yearly preventative exam code? I cannot believe the insurances will pay twice on a charge that is a once a year deal. What do I do?

Thank you !:eek:
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Are these denials coming from a specific payer? If so, I wonder if that payer's policy states prevents need to be performed by the PCP. If that's the case and the patient opted to have the services done by the OB/GYN, they are probably responsible for the charges. It all depends on the policy and your contract, if you have one with the payer.

If this isn't a specific payer, I'm not sure why it would be denied, because from a coding perspective, it is correct. I'd be interested to hear if other OB/GYNs have come across this.
 
GYN vs PCP preventative exams

I believe the claims are denying because most insurance carriers only cover one preventative exam per year. This can be tricky though as some carriers state "once per calendar year" or "once per each 12 mos period". If both the PCP and the gyn bill a preventative exam, the subsequent provider's claim will most likely be denied with a reasoning of "maximum routine benefit has been reached". Furthermore, most insurance carriers put a cap on the routine care benefit which also would include fees for routine labs. Working in family practice, we see this as well. When our female patients get their pap smears with a gyn, we have to ask the patient if they know how it was billed, so we know how to record and bill their annual physicals. We know it is a physical but we will bill as an E&M visit if able. However if a patient does not have a diagnosis other than a "v" code, then she will most likely be responsible for the bill and is made aware of that in advance.
 
Wouldn't you bill the preventive visit code with V72.31 for the GYN portion of the visit if you were only performing the gyn portion? I understand with Medicare you bill G0101 instead.

So if you were performing the annual phyiscal and the GYN portion would you not used the preventive visit CPT code and V70.0 and V72.31 for the dx?? for non medicare??
 
my other thought was what if you see a gyn for your yearly GYN exams and your PCP for your annual physical? is it not true that the diagnosis code would then be the determining factor for the insurance to pay each of those claims?? since women are allowed to seek out a gyn for this type visit. Would they not bill a preventive visit code for their services as well?

If it were a Medicare pt we would bill G0101 and Q0091 for the GYN exam correct? but not for NON-Medicare carriers right?
 
Gyn Yearly

My qustion is: I was told that a general urine dip is included in a yearly exam. But what if the dip shows that they may have a UTI and then it is sent for culture to the lab. Can we bill for a problem as well as the yearly including a dx 599.0 with a 81003?
 
Medicare will not cover the preventive codes 99397 or diagnosis V70.0 for Gyn. The patient will get billed for it. The G0101 and Q0091 with V72.31 and V76.2 are specific to Medicare.
 
Anastasia said:
Medicare will not cover the preventive codes 99397 or diagnosis V70.0 for Gyn. The patient will get billed for it. The G0101 and Q0091 with V72.31 and V76.2 are specific to Medicare.
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The G0101 and the Q0091 are payer discretion allowed which means other carriers can reimburse for these and many do. Also you never use the V72.31 with the V76.2, look in the ICD-9 CM book the V76.2 is inclusive.
 
99397

If this patient has Medicare primary and for instance is 65+ going to the gyn dr for routine annual then bill 99397-GY, G0101-GA, Q0091-GA----V72.31 (if a full exam, pap smear, and breast & pelvic exam were performed). This is a problem for the patient if their plan states limited amount-# visits for routine services. Some patients will come to the office and state that they only want the pap smear, pelvic & breast exam so that they may be seen by their PCP for the full exam. If that is the case then only bill G0101-GA, Q0091-GA----V76.2.
the GY, and GA modifiers are used to indicate ABN form signed.l If not signed then use GZ.
Medicare only pays once every 24 months for these services, so most patients pay the entire amount after Medicare because 80% of 2nd insurance companies dont cover what Medicare hasnt allowed.
 
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