Squeaky Clean Claims for Women’s Preventive Services
By Manickavalli Anand M.Sc, CPC, PCA
Preventive medicine services describe comprehensive evaluation and management (E/M) services provided to patients with no current symptoms or diagnosed illness. Preventive codes are used to report annual well woman examinations and include the following:
- Counseling/anticipatory guidance/risk factor reduction interventions
- Age and gender appropriate comprehensive history
Age and gender appropriate comprehensive physical examination including in most cases but not limited to:
- Gynecological exam
- Breast exam
- Collection of a Pap smear specimen
- Discussions about the status of previously diagnosed stable conditions
- Ordering of appropriate laboratory/diagnostic procedures and immunizations
- Discussions about issues related to the patient’s age or lifestyle
Preventive medicine codes 99381-99387 and 99391-99397 differ from problem-oriented E/M services in several ways. Preventive codes do not require a chief complaint, history of present illness (HPI), or medical decision making (MDM); cannot be reported using time; and may be performed in any setting. The Centers for Medicare & Medicaid Services’ (CMS) 1995 and 1997 Documentation Guidelines for Evaluation and Management Services do not apply to preventive services codes.
Medicare and other payers have different rules for reporting and reimbursing these services. Physicians should check with their specific commercial carries about their rules.
Medicare Screening Services
Medicare does not cover comprehensive preventive medicine services 99387 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization(s), laboratory/diagnostic procedures, new patient; 65 years and over or 99397 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization(s), laboratory/diagnostic procedures, established patient; 65 years and over; however, Medicare may cover certain services provided during preventive visits.
Collection of Screening Pap Smear Specimen
In most cases, Medicare reimburses for collection of a screening Pap smear every two years. This service is reported using HCPCS Level II code Q0091 Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory. The deductible is not applicable, but the coinsurance applies.
If the patient meets Medicare’s criteria for high-risk, the collection is reimbursed every year. Medicare considers a patient high-risk if a woman is of childbearing age AND cervical or vaginal cancer is present (or was present) or abnormalities were found within last three years.
A woman is also considered high-risk if she is not of childbearing age AND she has at least one of the following factors:
- High risk factors for cervical cancer:
- Onset of sexual activity under 16 years of age
- Five or more sexual partners in a lifetime
- History of sexually transmitted disease (including HIV)
- Fewer than three years negative Pap smear within the previous seven years
- No Pap smears at all within the previous seven years
- High risk factors for vaginal cancer such as having been exposed to DES (diethylstilbestrol) in utero
The diagnosis codes for collection of a Pap smear are:
V15.89 Other personal history presenting hazards to health; other. This diagnosis is reported for patient considered high risk according to the above criteria.
V72.31 Special investigations and examinations; gynecological examination; routine gynecological examination. This diagnosis is reported only when the provider performs a full gynecological examination in addition to screening services.
V76.2 Special screening for malignant neoplasm; cervix
V76.47 Special screening for malignant neoplasm; other sites; vagina (post-hysterectomy for non-malignant condition)
V76.49 Special screening for malignant neoplasm; other sites
Screening Pelvic Exam and Breast Check
In most cases, Medicare reimburses for pelvic examination and clinical breast check every two years. This service is reported using HCPCS Level II code G0101 Cervical or vaginal cancer screening; pelvic and clinical breast examination.
If the patient meets Medicare’s criteria for high-risk, the examination is reimbursed every year. These criteria and diagnosis codes are the same as the ones listed above.
To report code G0101, the following must be documented:
- Inspection and palpation of breast for masses or lumps; tenderness, symmetry, or nipple discharge; AND
- Perform and document 6 of the following 10 elements;
- Digital rectal examination including: sphincter tone, presence of hemorrhoids and rectal masses; pelvic examination (with or without specimen collection for smears and cultures)
- External genitalia (e.g. general appearance, hair distribution, or lesions)
- Urethra meatus (e.g. size, location, lesions, or prolapse)
- Urethra (e.g. masses, tenderness, or scarring)
- Bladder (e.g. fullness, masses, or tenderness)
- Vagina (e.g. general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, or rectocele)
- Cervix (e.g. general appearance, lesion, or discharge)
- Uterus (e.g. size, contour, position, mobility, tenderness, consistency, descent, or support)
- Adnexa/parametria (e.g. masses, tenderness, organomegaly, or nodularity)
- Anus and perineum
Only the above elements are included in HCPCS Level II code G0101. Any additional preventive services can be billed to the patient.
Medicare Screening Services During Same Encounter
Medicare preventive coverage includes a pelvic examination and clinical breast check (G0101) and collection of Pap smear specimen (Q0091). It does not include other services normally included in a preventive exam, such as taking vital signs, examining skin, heart, lungs, and reviewing systems, past family, and social history.
If more than one preventive service is provided during the same encounter, a physician should submit the screening codes to Medicare for payment and the preventive code to the patient for payment. The amount reimbursed by Medicare for the covered screening services is deducted from the amount billed to the patient for the other preventive services.
For example, Dr. Esther Jacob saw Monica for her annual gynecological exam. Medicare covered the collection of a Pap smear, the pelvic exam, and the clinical breast check. Dr. Esther Jacob usual charges $120 for an annual exam. She submitted:
Special screening for malignant neoplasms, cervix
Pelvic exam and breast checkQ0091
Collection of Pap smear
Preventive visit, established patient
* Appropriate Medicare allowable amount.
** Modifier 52 Reduced services is used here to illustrate that the patient is responsible for less than the full charge for the preventive medicine services. It is not necessary to use the modifier on the claim form.
Other Screening Services Covered by Medicare
Medicare also reimburses for colorectal cancer screening, mammogram, bone density studies, the initial preventive physical examination (known as the “Welcome to Medicare” exam), diabetes screening, cardiovascular screening, and tobacco cessation counseling.
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