Coding Consult

October 7, 2005

Well-woman exams

Break out services for Medicare

If you provide a well-woman exam for a Medicare patient, you should report G0101 (cervical or vaginal cancer screening; pelvic and clinical breast examination) for the breast and pelvic exams. When you also obtain a Pap smear, use Q0091 (screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory), says Carol Pohlig, a coding specialist at the University of Pennsylvania Medical Center in Philadelphia.

For Medicare patients at low risk for developing cervical or vaginal cancer, you can report a Pap test only once every two years. Beginning this past July, you're now permitted to use diagnosis code V72.31 (routine gynecological examination) when you bill for a screening Pap test, as long as you do a full gyn exam. You can also use this code when you do a screening pelvic exam-without doing a Pap test. This diagnosis code joins the other applicable codes that Medicare accepts when reporting a Pap test for a low-risk patient:

Another recent change to Pap test coding rules: Suppose the lab informs you that the specimen is inadequate for determination and you have to report Q0091 a second time. Medicare now allows you to attach modifier –76 (repeat procedure by same physician) to Q0091, which tells the carrier that you had to repeat the procedure and to allow payment. You should report the resubmitted Pap smear (Q0091) with V76.2, V76.47, or V76.49. In this case you wouldn't use V72.31 because you didn't perform a full gynecological exam.

If you're going to do a screening Pap that you know won't be covered by Medicare because the two-year period between Paps isn't up and the patient isn't high-risk, you must get an Advance Beneficiary Notice (ABN). Use the GA modifier on the claim to indicate that you got an ABN.

If the patient is high risk, you can bill the Pap tests annually. Use diagnosis code V15.89 (other specified personal history presenting hazards to health; other). The high risk factors can be any of the following:

Coding for commercial insurers

Although most commercial payers follow Medicare's lead, many don't accept G0101 or Q0091 for well-woman visits. With these insurers, you may report one of CPT's preventive medicine codes (99381-99397), depending on your payer's policies, says Pohlig.