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Coding Consult: Know Medicare's rules on screening exams


Know Medicare's rules on screening exams


Coding Consult

Know Medicare's rules on screening exams

By Fred Chafin, CPC

Q: One of our established Medicare patients came to see us for a sore throat. He also requested a prostate exam. Can I bill separately for the prostate exam?

A: No. The Correct Coding Initiative states that a prostate exam (G0102) is a component of established-patient E&M codes and can't be unbundled. However, you can bill for a prostate exam if that's the only service you've provided to the patient that day, and he hasn't had such an exam within the past 12 months.

Some doctors have a PA or NP perform all of the practice's digital rectal exams on one or two days per month. On that day, no other E&M services are performed for those patients. The fee for G0102 is approximately $20. It's a good idea to get a signed waiver from the patient stating that no other physician has billed for the exam within the last 12 months.

Q: Can I bill for a PSA (G0103) performed during the same visit as the digital rectal exam?

A: Yes.

Q: Can I bill for cervical or vaginal cancer screening exams (G0101) on my female Medicare patients?

A: Yes. Current coverage allows one pelvic examination for female beneficiaries every three years, but next month that changes to once every two years. Payment is allowed once a year for the rare Medicare woman of childbearing age and for those at high risk for cervical cancer. When you see a patient for other reasons the same day, use modifier ­25 for the screening claim. Reimbursement is approximately the same as for a 99211.

For pelvic screening examinations, you must include at least seven of the following areas:

• Breasts, including inspection or palpation for masses or lumps, tenderness, symmetry, or nipple discharge.

• Digital rectal examination for sphincter tone, presence of hemorrhoids, and rectal masses.

• Pelvic examination (with or without specimen collection for smears and culture), including external genitalia (general appearance, hair distribution, lesions).

• Urethral meatus (size, lesions, prolapse).

• Urethra (masses, tenderness, scarring).

• Bladder (fullness, masses, tenderness).

• Vagina (general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele).

• Cervix (general appearance, lesions, discharge).

• Uterus (size, contour, position, mobility, tenderness, consistency, descent, support).

• Adnexa/parametria (masses, tenderness, organomegaly, nodularity).

• Anus and perineum.

Q: Can I also bill for the specimen collection for a Pap smear (Q0091)?

A: Yes. This is billable once every three years as a screening procedure and once a year for all patients at high risk. Medicare considers a patient at high risk for cervical cancer for the following reasons: five or more sex partners in a lifetime, sexual activity before age 16, history of sexually transmitted disease (including HIV), and fewer than three negative Pap smears within the past seven years.

Patients are considered at risk for vaginal cancer if ever exposed to DES.

Q: How about colorectal cancer screening? What can I bill?

A: Medicare pays for a fecal occult blood test, one to three simultaneous determinations (G0107), every 12 months for covered patients 50 years and older. For those at high risk, Medicare pays for a colonoscopy (G0105) every two years. For those not at high risk, Medicare begins next month to pay for a screening colonoscopy once every 10 years.

Q: How frequently will Medicare cover screening flexible sigmoidoscopies?

A: Medicare will pay for diagnostic flexible sigmoidoscopy (G0104) for covered patients 50 years or older once every four years. You should order the test in writing, and it must be performed by you or another physician. Medicare will pay for a barium enema (G0106) as an alternative to a flex sig every four years.

The author, a certified professional coder, is a consultant and seminar leader for McVey Associates (mcveyseminars.com), an insurance reimbursement consulting company in Novato, CA. This department answers common coding questions. Since coding rules frequently change and are subject to interpretation by insurance carriers, decisions should be made in light of individual circumstances, local conditions, payer policies, contracts, and new or pending governmental policies. We welcome your questions for future columns. Please submit them to mecode@medec.com. Sorry, but we're not able to answer readers individually.

Medicare screening rules

Billable with E&M code
Digital rectal exam prostate cancer screening (G0102)
Once every year
PSA, total (G0103)
Once every year
Pelvic screening exam (G0101)
Once every two years as of July 1, 2001
Yes, with modifier –25
Pap smear collection (Q0091)
Once every three years (once a year for high-risk patients)
Yes, with modifier –25
Fecal occult blood test colorectal cancer screening (G0107)
Once a year for all patients 50 years and older
Yes, with modifier –25
Flexible sigmoidoscopy colorectal cancer screening (G0104)
Once every four years for all patients 50 years and older
Yes, with modifier –25
Barium enema colorectal cancer screening (G0106)
Once every four years as an alternative to flexible sigmoidoscopy
Yes, with modifier –25
Colonoscopy colorectal cancer screening (G0105)
Once every two years for patients 50 years and older at high risk of colorectal cancer. Effective July 1, 2001, once every 10 years for individuals not at high risk
Yes, with modifier –25


Fred Chafin. Coding Consult: Know Medicare's rules on screening exams. Medical Economics 2001;11:28.

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