FW: How to bill medicare pap - Need Help please

[Guest guest]

Helen,

The following is the text from a handout on OBGYN coding that I

got last year at a conference I attended. The 1st part covers Medicare.

The next part covers info from certain other payers and some Medicare advantage

plans. At the end is info on repeat PAPs and E & M with preventative

coding. Hope it helps.

Beth Sullivan, DO

Ridgeway Family Practice

Commerce, GA 30529

Screening GYN

Exams

Documentation,

Coding, and Billing Guidelines

These guidelines apply to screening exams only.

If the patient presents with a GYN problem, bill a “regular”

problem-oriented E & M service.

PART ONE – Medicare

Documentation of screening

GYN exams per CMS Guidelines:

Must

include at least seven of the following eleven elements:

§ Inspection and palpation of breasts for masses or lumps,

tenderness, symmetry, or nipple discharge; and

§ Digital rectal examination including sphincter tone, presence of

hemorrhoids, and rectal masses.

§ External genitalia (for example, general appearance, hair

distribution, or lesions);

§ Urethral meatus (for example, size, location, lesions, or

prolapse);

§ Urethra (for example, masses, tenderness, or scarring);

§ Bladder (for example, fullness, masses, or tenderness);

§ Vagina (for example, general appearance, estrogen effect,

discharge, lesions, pelvic support, cystocele, or rectocele);

§ Cervix (for example, general appearance, lesions or discharge)

§ Uterus (for example, size, contour, position, mobility,

tenderness, consistency, descent, or support);

§ Adnexa/parametria (for example, masses, tenderness, organomegaly,

or nodularity); and

§ Anus and perineum.

I.

Coverage information

per CMS Guidelines:

Medicare covers screening Pap smears

and screening pelvic exams once every 12 months for women who:

Are of childbearing age & have had an exam

in the previous 3 year that indicated the presence of cervical or vaginal

cancer or other abnormalities; or

Are considered high risk for

developing cervical or vaginal cancer.

High Risk Criteria:

Early onset of sexual activity (under 16 years of age)

Multiple sexual partners (five or more in a lifetime)

History of a sexually transmitted disease (including HPV & HIV)

Fewer than three negative Pap tests within the previous seven years

DES (diethylstilbestrol)-exposed daughters of women who took DES during

pregnancy

Pap smears and pelvic exams for all other women (low

risk) are covered every 2 years.

The

provider MUST indicate high-risk or low-risk on the encounter form. If it

is not indicated, the coding department will assume the patient is low-risk.

II.

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

·

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)

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)

Tricare

·

G0101

and Q0091

·

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

·

Waiting for answer from provider rep. Bill

G0101 and Q0091 for now. (Did receive payments!!!)

For any

insurance not listed here, bill the G0101 and Q0091.

We will track denials

and payments and update the policy as needed.

Problem

visit on same day as screening GYN Exam:

If

a separate and significant E & M service was performed to address a problem

on the same day as the screening GYN exam, the provider may indicate a separate

“problem-oriented” visit (e.g. 99213).

·

Use

modifier -25 on the ‘problem visit’ and ‘link’ problem

diagnoses (do not link V72.31 to the problem visit). **EXCEPT FOR

MASSHEALTH – bill only preventive exam.

·

Except

for Fallon, see above.

Repeat

Pap Smears:

If

the provider indicates a repeat Pap due to inadequate prep, use dx code 795.08

and the procedure code will be as follows:

·

For

payors who accept Q0091, use the Q0091 with -76 Modifier.

·

For

everyone else, bill a low-level (e.g. 99212) and specimen handling, 99000.

Updated 02.05.09

a Schwalm

From: Helen Yang

Sent: Wednesday, February 10, 2010 10:19 PM

To: bethdo97@...

Subject: How to bill medicare pap - Need Help please

Hi Beth,

Could you please show me how to bill medicare for Q0091 PAP q 2 y and G0101

breast exam (year?) for medicare patients? Could we bill them with a 99214?

Need any modifier?

Thank you very much.

Helen

To:

From: bethdo97@...

Date: Tue, 9 Feb 2010 07:56:42 -0500

Subject: RE: High School Presentation - Need Help

Will check these out during lunch today.

Beth Sullivan, DO

Ridgeway Family Practice

Commerce, GA 30529

From:

[mailto: ] On Behalf Of Kathy

Saradarian

Sent: Tuesday, February 09, 2010 7:42 AM

To:

Subject: RE: High School Presentation - Need Help

Try familypractice.org, I remember when doing a nutrition talk

for Girl Scouts they had a whole section aimed at kids. Also Mayo patient

ed, Cleveland Clinic patient ed .

Kathy Saradarian, MD

Branchville, NJ

www.qualityfamilypractice.com

Solo 4/03, Practicing since 9/90

Practice Partner 5/03

Low staffing

From:

[mailto: ] On Behalf Of Beth

Sullivan, DO

Sent: Tuesday, February 09, 2010 5:22 AM

To: Practice Management Issues; Practice Improvement

Subject: High School Presentation - Need Help

I

am doing a presentation to 10-12 grade female students at a local high school

on Friday Afternoon. They want me to talk about Pap Smears, STD’s,

and Birth Control Options. I have been trying to find some handouts to

use that would be appropriate for the age of the audience. If anyone has

any suggestions or resources they might be willing to share I would be

extremely appreciative. Thanks in advance

Beth

Sullivan, DO

Ridgeway

Family Practice

Commerce,

GA 30529

Hotmail:

Trusted email with Microsoft’s powerful SPAM protection. Sign up

now.